Provider Demographics
NPI:1407174576
Name:BALUSIK, NATHAN SHANE
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:SHANE
Last Name:BALUSIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 WATERVILLE MONCLOVA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-1099
Mailing Address - Country:US
Mailing Address - Phone:419-878-3010
Mailing Address - Fax:419-878-3236
Practice Address - Street 1:900 WATERVILLE MONCLOVA RD
Practice Address - Street 2:SUITE A
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-1099
Practice Address - Country:US
Practice Address - Phone:419-878-3010
Practice Address - Fax:419-878-3236
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.120628207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35 120628OtherSTATE LICENSE