Provider Demographics
NPI:1235129370
Name:BALZER, LARRY DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DALE
Last Name:BALZER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S BRYANT
Mailing Address - Street 2:SUITE #210
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034
Mailing Address - Country:US
Mailing Address - Phone:405-359-5229
Mailing Address - Fax:405-359-5214
Practice Address - Street 1:105 S BRYANT AVE
Practice Address - Street 2:SUITE #210
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6399
Practice Address - Country:US
Practice Address - Phone:405-359-5229
Practice Address - Fax:405-359-5214
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1498207QG0300X
OK9795207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00231789OtherRAIL ROAD RETIREMENT ID
TX108018103OtherFIRSTCARE PROVIDER NUMBER
TX115029404Medicaid
OK100116910AMedicaid
TX4060556OtherHEALTHMARKET
TX115029404Medicaid
OK100116910AMedicaid
TX4060556OtherHEALTHMARKET
OKOKA100357Medicare PIN
TX108018103OtherFIRSTCARE PROVIDER NUMBER