Provider Demographics
NPI:1689766537
Name:BALTER, RICHARD A (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:BALTER
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 1:5225-15 ROUTE 347
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776
Mailing Address - Country:US
Mailing Address - Phone:631-331-1000
Mailing Address - Fax:
Practice Address - Street 1:5225-15 ROUTE 347
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-331-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139759207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110042573OtherRAILROAD MEDICARE
2291016OtherAETNA
7181524005OtherCIGNA
12545OtherVYTRA
NY00699683Medicaid
2291016OtherAETNA
B78913Medicare UPIN
NY67A9608991Medicare PIN