Basic Information
| Provider Information | |||||||||
| NPI: | 1174515969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALCAZAR | ||||||||
| FirstName: | MIRTHA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 496084 | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960496084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303474867 | ||||||||
| FaxNumber: | 5303475670 | ||||||||
| Practice Location | |||||||||
| Address1: | 20633 GAS POINT RD | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960229296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303474867 | ||||||||
| FaxNumber: | 5303475670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A44843 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A448430 | 05 | CA | MEDICAID |