Provider Demographics
NPI:1710017389
Name:BALDWIN, JACK PAYTE (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:PAYTE
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 UNIVERSITY
Mailing Address - Street 2:#203
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670
Mailing Address - Country:US
Mailing Address - Phone:903-935-1233
Mailing Address - Fax:
Practice Address - Street 1:304 UNIVERSITY
Practice Address - Street 2:#203
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670
Practice Address - Country:US
Practice Address - Phone:903-935-1233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6988207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C13104Medicare UPIN
TX00BB61Medicare ID - Type Unspecified