Provider Demographics
NPI:1407801152
Name:BALDWIN, TREVOR J (OD)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:J
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 1:1721 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-3161
Mailing Address - Country:US
Mailing Address - Phone:608-837-7325
Mailing Address - Fax:608-837-7326
Practice Address - Street 1:1721 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-3161
Practice Address - Country:US
Practice Address - Phone:608-837-7325
Practice Address - Fax:608-837-7326
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1926-035152WC0802X, 152W00000X
156FX1201X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric Assistant
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
000247780OtherMEDICARE PROVIDER NUMBER
U37289Medicare UPIN
WI5024830001Medicare NSC