Provider Demographics
NPI:1376122028
Name:BALKENBUSH, JEFFREY T (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:T
Last Name:BALKENBUSH
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 1:2009 RIDGECREST RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-6662
Mailing Address - Country:US
Mailing Address - Phone:405-301-6297
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST # 530
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program