Provider Demographics
NPI:1063765709
Name:BALDWIN, BRAD (LAC)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8102 AMELIA RD APT K504
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-2047
Mailing Address - Country:US
Mailing Address - Phone:214-533-9901
Mailing Address - Fax:
Practice Address - Street 1:2855 MANGUM RD STE 433
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-7484
Practice Address - Country:US
Practice Address - Phone:214-533-9901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3549246ZE0600X
TXAC01245171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic