Provider Demographics
NPI:1073639613
Name:BALKAM, STEPHEN MITCHELL (PT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MITCHELL
Last Name:BALKAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 47TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-3626
Mailing Address - Country:US
Mailing Address - Phone:619-262-7342
Mailing Address - Fax:619-262-8918
Practice Address - Street 1:1005 47TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-3626
Practice Address - Country:US
Practice Address - Phone:619-262-7342
Practice Address - Fax:619-262-8918
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA212652251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics