1417022484 NPI number — DR. WILLIAM BALOGH

Table of content: (NPI 1417022484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417022484 NPI number — DR. WILLIAM BALOGH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. WILLIAM BALOGH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1417022484
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2016 S 320TH ST
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
FEDERAL WAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98003-5453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-839-1610
Provider Business Mailing Address Fax Number:
253-839-0755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2016 S 320TH ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-5453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-839-1610
Provider Business Practice Location Address Fax Number:
253-839-0755
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BURGOS
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
253-839-1610

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  O.D.00001030 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: WA0006 . This is a "NBN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3909 . This is a "DAVIS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: BA3096 . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 02781 . This is a "SPECTERA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2052900 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 212835 . This is a "EYEMED" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: AETNA . This is a "44132B" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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