Provider Demographics
NPI:1093890105
Name:BALDWIN, REGINALD JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:JAMES
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 HARBOR ST
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:590 HARBOR ST
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1904
Practice Address - Country:US
Practice Address - Phone:805-772-1269
Practice Address - Fax:805-772-2172
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5498152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0054980Medicaid
CA0215340001Medicare NSC
CAOP5498Medicare UPIN