Provider Demographics
NPI:1922379379
Name:JOHN S BALKNAP DPM PC
Entity Type:Organization
Organization Name:JOHN S BALKNAP DPM PC
Other - Org Name:MT. HOOD PODIATRY THE DALLES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDMARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-228-7106
Mailing Address - Street 1:1716 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3137
Mailing Address - Country:US
Mailing Address - Phone:541-296-1006
Mailing Address - Fax:541-298-1613
Practice Address - Street 1:1716 E 12TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3137
Practice Address - Country:US
Practice Address - Phone:541-296-1006
Practice Address - Fax:541-298-1613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty