Provider Demographics
NPI:1922254705
Name:BALOUCH, JAMAL ABDUL YASSER (DO)
Entity Type:Individual
Prefix:MR
First Name:JAMAL
Middle Name:ABDUL YASSER
Last Name:BALOUCH
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 1:500 15TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4324
Mailing Address - Country:US
Mailing Address - Phone:406-455-5000
Mailing Address - Fax:406-731-8318
Practice Address - Street 1:500 15TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4324
Practice Address - Country:US
Practice Address - Phone:406-455-5000
Practice Address - Fax:406-731-8318
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT341712081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1545Medicaid
NC5919902Medicaid
NC5919902Medicaid
NCNC4925BMedicare PIN