Provider Demographics
NPI:1427316041
Name:BALDWIN, JEREMIAH JOHN (IDC)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:JOHN
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 YUCCA DR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-3904
Mailing Address - Country:US
Mailing Address - Phone:360-969-1720
Mailing Address - Fax:
Practice Address - Street 1:5303 MARVIN SHIELDS BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-9013
Practice Address - Country:US
Practice Address - Phone:228-822-5790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman