Provider Demographics
NPI:1184770281
Name:BALTHASER, ERIC LEE (OD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:LEE
Last Name:BALTHASER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 MACOMB
Mailing Address - Street 2:
Mailing Address - City:MT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:586-464-1472
Practice Address - Street 1:4920 MILAN RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:419-624-0456
Practice Address - Fax:419-624-9215
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5370T2281152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist