Provider Demographics
NPI:1265818843
Name:BALFANZ, MICHAEL JOHN (WLMT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:BALFANZ
Suffix:
Gender:M
Credentials:WLMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 DOOR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-2842
Mailing Address - Country:US
Mailing Address - Phone:608-712-2775
Mailing Address - Fax:
Practice Address - Street 1:2585 DOOR CREEK RD
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-2842
Practice Address - Country:US
Practice Address - Phone:608-712-2775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI146-11537171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor