Provider Demographics
NPI:1033260351
Name:BALEZENTIS, SUSAN M (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:BALEZENTIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 634863
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0042
Mailing Address - Country:US
Mailing Address - Phone:800-290-5282
Mailing Address - Fax:937-534-0166
Practice Address - Street 1:967 N BROADWAY
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1301
Practice Address - Country:US
Practice Address - Phone:914-964-4376
Practice Address - Fax:937-534-0166
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211889-1207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH07860Medicare UPIN
NY3H2891Medicare ID - Type Unspecified