Basic Information
| Provider Information | |||||||||
| NPI: | 1811095342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALDING | ||||||||
| FirstName: | CARMEN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MANSILLA-ORIHUELA | ||||||||
| OtherFirstName: | CARMEN | ||||||||
| OtherMiddleName: | S | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 788 N. JEFFERSON STREET | ||||||||
| Address2: | SUITE 300 / ATTN. KAAREN BUTZEN | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532023710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142728950 | ||||||||
| FaxNumber: | 4142720859 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 W. RIVER WOODS PRKWY | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143261514 | ||||||||
| FaxNumber: | 4143261574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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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 | 207N00000X | 47048 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | 47048 | WI | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1811095342 | 05 | WI | MEDICAID |