Basic Information
| Provider Information | |||||||||
| NPI: | 1376524603 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALAZSY | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD, DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122165 DEPT 2165 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753122165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374944900 | ||||||||
| FaxNumber: | 3374944936 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 OAK PARK BLVD FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374944900 | ||||||||
| FaxNumber: | 3374944936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 08/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 312731 | LA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 91108 | 01 | FL | BCBS OF FLORIDA | OTHER | 818053 | 01 | LA | MEDICARE | OTHER | 4303052 | 05 | MI | MEDICAID | ME92348 | 01 | FL | FLORIDA MEDICAL LICENSE | OTHER |