Provider Demographics
NPI:1194856427
Name:BALOURDAS, GREGORY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MICHAEL
Last Name:BALOURDAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4101 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1342
Mailing Address - Country:US
Mailing Address - Phone:619-291-2430
Mailing Address - Fax:619-291-4048
Practice Address - Street 1:4101 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1342
Practice Address - Country:US
Practice Address - Phone:619-291-2430
Practice Address - Fax:619-291-4048
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51351207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B57929Medicare UPIN