Provider Demographics
NPI:1457315038
Name:BALT, DAVID A (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:BALT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTEN MEDICAL STAFF SERVICES
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6000
Mailing Address - Country:US
Mailing Address - Phone:605-719-7109
Mailing Address - Fax:605-719-1027
Practice Address - Street 1:1440 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1505
Practice Address - Country:US
Practice Address - Phone:605-644-4004
Practice Address - Fax:605-644-4006
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN37593207Q00000X
SD1971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN791313300Medicaid
MN791313300Medicaid
MNE51053Medicare UPIN