Provider Demographics
NPI:1952495970
Name:BALKOVEC, DALE A (DO)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:A
Last Name:BALKOVEC
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 1:15003 TURNEY ROAD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137
Mailing Address - Country:US
Mailing Address - Phone:216-663-7753
Mailing Address - Fax:216-663-0897
Practice Address - Street 1:15003 TURNEY RD
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-4730
Practice Address - Country:US
Practice Address - Phone:216-663-7753
Practice Address - Fax:216-663-0897
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003692207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341682240BA02OtherEMERALD
OH9000017231OtherHMP
OH000000136583OtherANTHEM
OH0588645Medicaid
OH080039459OtherRAILROAD MEDICARE
OHT03692OtherSUMMA
OH080039459OtherRAILROAD MEDICARE
A16038Medicare UPIN