Provider Demographics
NPI:1568464147
Name:BALCH, EMMET HEZEKIAH III (MD)
Entity Type:Individual
Prefix:DR
First Name:EMMET
Middle Name:HEZEKIAH
Last Name:BALCH
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1845 PRECINCT LINE RD STE 209
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3109
Mailing Address - Country:US
Mailing Address - Phone:817-336-4638
Mailing Address - Fax:817-336-1331
Practice Address - Street 1:1845 PRECINCT LINE RD STE 209
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3109
Practice Address - Country:US
Practice Address - Phone:817-336-4638
Practice Address - Fax:817-336-1331
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF91632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124445102Medicaid
TX80R342OtherMEDICARE - PTAN
TX124445102Medicaid