Provider Demographics
NPI:1083770887
Name:BAULDRY, DOUGLAS DAN
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:DAN
Last Name:BAULDRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 E 10TH PL
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-3677
Mailing Address - Country:US
Mailing Address - Phone:520-876-5700
Mailing Address - Fax:
Practice Address - Street 1:1327 E 10TH PL
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-3677
Practice Address - Country:US
Practice Address - Phone:520-876-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10761385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child