MEDICARE: TREVOR J BALDWIN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WC0802X	Corneal and Contact Management Optometrist	1926-035	WI
2	156FX1201X	Optometric Assistant Technician
3	156FX1800X	Optician
4	152W00000X	Optometrist	1926-035	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000247780	OTHER		MEDICARE PROVIDER NUMBER

General Provider Information

NPI Number	:	1407801152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TREVOR J BALDWIN OD

Provider Business Mailing Address
First Line	:	1721 W MAIN ST
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-3161
Country	:	US
Telephone Number	:	608-837-7325
Fax Number	:	608-837-7326

Provider Business Practice Location Address
First Line	:	1721 W MAIN ST
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-3161
Country	:	US
Telephone Number	:	608-837-7325
Fax Number	:	608-837-7326

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	02/08/2021

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