Healthcare Provider Details

I. General information

NPI: 1366794695
Provider Name (Legal Business Name): SCOTT BALDWIN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 TANGLEFOOT LN
BETTENDORF IA
52722-1650
US

IV. Provider business mailing address

777 TANGLEFOOT LN
BETTENDORF IA
52722-1650
US

V. Phone/Fax

Practice location:
  • Phone: 563-323-2020
  • Fax: 563-459-6615
Mailing address:
  • Phone: 563-323-2020
  • Fax: 563-459-6615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number078387
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: