Provider Demographics
NPI:1477751774
Name:BALCH, ROBERT JUDSON III (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JUDSON
Last Name:BALCH
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4319 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3893
Mailing Address - Country:US
Mailing Address - Phone:817-984-6210
Mailing Address - Fax:817-984-6216
Practice Address - Street 1:4319 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-984-6210
Practice Address - Fax:817-984-6216
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-07
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM65132081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0068WBOtherBCBS
P00940987Medicare PIN
TX0068WBOtherBCBS