Provider Demographics
NPI:1922001817
Name:BALKCOM, ICHABOD LAFAYETTE IV (MD)
Entity type:Individual
Prefix:
First Name:ICHABOD
Middle Name:LAFAYETTE
Last Name:BALKCOM
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10481 HWY 31 E
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75705-2389
Mailing Address - Country:US
Mailing Address - Phone:903-243-1110
Mailing Address - Fax:
Practice Address - Street 1:10481 HWY 31 E
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75705-2389
Practice Address - Country:US
Practice Address - Phone:903-243-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139946124Medicaid
D44788Medicare UPIN
TXTXB132817Medicare PIN