Provider Demographics
NPI:1417941055
Name:BALBOA, RONALDO S (MD)
Entity Type:Individual
Prefix:
First Name:RONALDO
Middle Name:S
Last Name:BALBOA
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 1:1201 STONE ST
Mailing Address - Street 2:STE. 5
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3563
Mailing Address - Country:US
Mailing Address - Phone:810-966-9556
Mailing Address - Fax:810-966-4898
Practice Address - Street 1:1201 STONE ST
Practice Address - Street 2:STE. 5
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3563
Practice Address - Country:US
Practice Address - Phone:810-966-9556
Practice Address - Fax:810-966-4898
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRB028997207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1006297Medicaid
MI0740374Medicare PIN
MIB45815Medicare UPIN