Provider Demographics
NPI:1598737116
Name:BALACUIT, DONALD (DO)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:
Last Name:BALACUIT
Suffix:
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 1:416 S MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-2812
Mailing Address - Country:US
Mailing Address - Phone:626-357-3296
Mailing Address - Fax:626-359-5608
Practice Address - Street 1:416 S MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2812
Practice Address - Country:US
Practice Address - Phone:626-357-3296
Practice Address - Fax:626-359-5608
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7756207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207375700Medicaid
MO207375700Medicaid
MO932003535Medicare PIN
MO890462OtherCOMMUNITY CARE PLUS
MO207375700Medicaid
MO198320OtherBCBS
MOI02315OtherMERCY HEALTH
MO55896OtherGHP
MO55896OtherHEALTHCARE USA
MOP00270563OtherRAILROAD MEDICARE