Provider Demographics
NPI:1467450668
Name:BALTISBERGER, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:BALTISBERGER
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 1:1865 TAMARACK RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1350
Mailing Address - Country:US
Mailing Address - Phone:220-564-4940
Mailing Address - Fax:220-564-4930
Practice Address - Street 1:1865 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1350
Practice Address - Country:US
Practice Address - Phone:220-564-4940
Practice Address - Fax:220-564-4930
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071353208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2109971Medicaid