Provider Demographics
NPI:1124013925
Name:BALKE, SUSAN WANDA (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:WANDA
Last Name:BALKE
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 1:171 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:AR
Mailing Address - Zip Code:72360-1938
Mailing Address - Country:US
Mailing Address - Phone:870-295-6205
Mailing Address - Fax:
Practice Address - Street 1:171 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:AR
Practice Address - Zip Code:72360-1938
Practice Address - Country:US
Practice Address - Phone:870-295-6205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-18
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN6963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR111863003Medicaid
C68168Medicare UPIN
AR111863003Medicaid