Provider Demographics
NPI:1245575588
Name:BALDWIN, DIMITRI
Entity Type:Individual
Prefix:
First Name:DIMITRI
Middle Name:
Last Name:BALDWIN
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 1:13 WILFRED ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-1643
Mailing Address - Country:US
Mailing Address - Phone:718-483-1178
Mailing Address - Fax:
Practice Address - Street 1:1250 WATERS PL
Practice Address - Street 2:SUITE 903
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2720
Practice Address - Country:US
Practice Address - Phone:718-652-0003
Practice Address - Fax:718-652-0815
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400080713Medicare PIN