Provider Demographics
NPI:1972613198
Name:BALACUIT, PETER C (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:C
Last Name:BALACUIT
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 1:416 S MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-2812
Mailing Address - Country:US
Mailing Address - Phone:626-357-3296
Mailing Address - Fax:626-359-5608
Practice Address - Street 1:416 S MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2812
Practice Address - Country:US
Practice Address - Phone:626-357-3296
Practice Address - Fax:626-359-5608
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33654207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A336540Medicaid
CAA33654BMedicare PIN
CAA87921Medicare UPIN