Provider Demographics
NPI:1174515969
Name:BALCAZAR, MIRTHA L (MD)
Entity type:Individual
Prefix:
First Name:MIRTHA
Middle Name:L
Last Name:BALCAZAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 496084
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-6084
Mailing Address - Country:US
Mailing Address - Phone:530-347-4867
Mailing Address - Fax:530-347-5670
Practice Address - Street 1:20633 GAS POINT RD
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:CA
Practice Address - Zip Code:96022-9296
Practice Address - Country:US
Practice Address - Phone:530-347-4867
Practice Address - Fax:530-347-5670
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA44843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A448430Medicaid
CA00A448430Medicare ID - Type Unspecified
CA00A448430Medicaid