1750340105 NPI number — MRS. KATHARINE J BALBUENA MD

Table of content: MRS. KATHARINE J BALBUENA MD (NPI 1750340105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750340105 NPI number — MRS. KATHARINE J BALBUENA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALBUENA
Provider First Name:
KATHARINE
Provider Middle Name:
J
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1750340105
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 734107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75373-4107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-284-9850
Provider Business Mailing Address Fax Number:
817-284-3425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 LINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71101-3841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-284-9850
Provider Business Practice Location Address Fax Number:
817-284-9859
Provider Enumeration Date:
03/22/2006

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: 208100000X , with the licence number:  K0624 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 029577601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0030QD . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8AJ344 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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