Provider Demographics
NPI:1205064581
Name:BALTZ, BRIAN ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ANTHONY
Last Name:BALTZ
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 1:210 W DREW AVE
Mailing Address - Street 2:PO BOX 747
Mailing Address - City:MONETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72447-9010
Mailing Address - Country:US
Mailing Address - Phone:870-486-5464
Mailing Address - Fax:870-486-1211
Practice Address - Street 1:210 W DREW AVE
Practice Address - Street 2:
Practice Address - City:MONETTE
Practice Address - State:AR
Practice Address - Zip Code:72447-9010
Practice Address - Country:US
Practice Address - Phone:870-486-5464
Practice Address - Fax:870-486-1211
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE7150207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR194152001Medicaid
5AP26OtherMEDICARE