Provider Demographics
NPI:1629281662
Name:BALUYUT, IRENE DALUSUNG (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:DALUSUNG
Last Name:BALUYUT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3569 ROUND BARN CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-5781
Mailing Address - Country:US
Mailing Address - Phone:707-303-3600
Mailing Address - Fax:
Practice Address - Street 1:3569 ROUND BARN CIR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-5781
Practice Address - Country:US
Practice Address - Phone:707-303-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87105208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0-489-641-1OtherECFMG#
CAA87105OtherCA MEDICAL LICENSE