Provider Demographics
NPI:1346205788
Name:BALES, MITZI M (MD)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:M
Last Name:BALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MITZI
Other - Middle Name:MARIE
Other - Last Name:BALES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9667
Practice Address - Street 1:3009 N CYPRESS DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-4003
Practice Address - Country:US
Practice Address - Phone:316-274-9900
Practice Address - Fax:316-687-3645
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-26016207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100282210CMedicaid
003719194OtherMEDICARE
003719194OtherMEDICARE