Provider Demographics
NPI:1184615981
Name:BALSALOBRE, AMANDA MARIE (OD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:BALSALOBRE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:GALSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19711 DARTMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3007
Mailing Address - Country:US
Mailing Address - Phone:541-556-8445
Mailing Address - Fax:
Practice Address - Street 1:762 E 13TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3778
Practice Address - Country:US
Practice Address - Phone:541-343-3333
Practice Address - Fax:541-484-5578
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3119T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR132149Medicare PIN
ORV06044Medicare UPIN
ORR132148Medicare PIN