Provider Demographics
NPI:1588693055
Name:BALDWIN, SUSAN (OD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6435 OAKCREEK WAY
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-6105
Mailing Address - Country:US
Mailing Address - Phone:916-961-0395
Mailing Address - Fax:916-961-0396
Practice Address - Street 1:430 BLUE RAVINE RD
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3402
Practice Address - Country:US
Practice Address - Phone:916-961-0395
Practice Address - Fax:916-961-0396
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11460T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050643OtherNVA
CA13748OtherMEDICAL EYE SERIVCES
CA941530OtherEYEMED
CASD0114600Medicaid
CAP00008191OtherRAILROAD MEDICARE
CASD0114600Medicaid
CAP00008191OtherRAILROAD MEDICARE