Healthcare Provider Details

I. General information

NPI: 1316924590
Provider Name (Legal Business Name): ANDREW J BALDUS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W PARADISE DR
WEST BEND WI
53095-9795
US

IV. Provider business mailing address

1700 W PARADISE DR
WEST BEND WI
53095-9795
US

V. Phone/Fax

Practice location:
  • Phone: 414-454-7734
  • Fax:
Mailing address:
  • Phone: 414-454-7734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2616
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: