Basic Information
| Provider Information | |||||||||
| NPI: | 1750340105 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALBUENA | ||||||||
| FirstName: | KATHARINE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 734107 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753734107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172849850 | ||||||||
| FaxNumber: | 8172843425 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 LINE AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711013841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003244777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | K0624 | TX | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 029577601 | 05 | TX | MEDICAID | 0030QD | 01 | TX | BCBS | OTHER | 8AJ344 | 01 | TX | BCBS | OTHER |