1235129370 NPI number — DR. LARRY DALE BALZER MD

Table of content: DR. LARRY DALE BALZER MD (NPI 1235129370)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235129370 NPI number — DR. LARRY DALE BALZER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALZER
Provider First Name:
LARRY
Provider Middle Name:
DALE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235129370
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 S BRYANT
Provider Second Line Business Mailing Address:
SUITE #210
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-359-5229
Provider Business Mailing Address Fax Number:
405-359-5214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 S BRYANT AVE
Provider Second Line Business Practice Location Address:
SUITE #210
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73034-6399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-359-5229
Provider Business Practice Location Address Fax Number:
405-359-5214
Provider Enumeration Date:
10/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X , with the licence number:  E1498 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X , with the licence number: 9795 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00231789 . This is a "RAIL ROAD RETIREMENT ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 108018103 . This is a "FIRSTCARE PROVIDER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 115029404 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100116910A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4060556 . This is a "HEALTHMARKET" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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