Provider Demographics
NPI:1164801205
Name:BALOV, TANYA MARIE (DO)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:MARIE
Last Name:BALOV
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 20610
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85277-0610
Mailing Address - Country:US
Mailing Address - Phone:833-584-1347
Mailing Address - Fax:
Practice Address - Street 1:845 E WARNER RD STE 101
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-1058
Practice Address - Country:US
Practice Address - Phone:480-981-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007621207Q00000X
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty