Provider Demographics
NPI:1205855202
Name:BALDWIN, JEFFERY D (PT)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:D
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 S HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-5704
Mailing Address - Country:US
Mailing Address - Phone:208-678-2405
Mailing Address - Fax:
Practice Address - Street 1:1224 8TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1527
Practice Address - Country:US
Practice Address - Phone:208-436-9016
Practice Address - Fax:208-436-4922
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806879600Medicaid
ID165 5006Medicare ID - Type Unspecified