Provider Demographics
NPI:1053470948
Name:ADAM, BALKOZAR S (MD)
Entity Type:Individual
Prefix:
First Name:BALKOZAR
Middle Name:S
Last Name:ADAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5000
Mailing Address - Fax:417-761-5011
Practice Address - Street 1:1300 E BRADFORD PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4264
Practice Address - Country:US
Practice Address - Phone:417-761-5000
Practice Address - Fax:417-761-5011
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5G052084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203506407Medicaid
025050196Medicare ID - Type Unspecified
MO203506407Medicaid
MO152360120Medicare PIN