Provider Demographics
NPI:1205924537
Name:BALOTIN, ROBERT JAY (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAY
Last Name:BALOTIN
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:PO BOX 2417
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-2417
Mailing Address - Country:US
Mailing Address - Phone:770-532-9936
Mailing Address - Fax:770-534-9877
Practice Address - Street 1:200 W ACADEMY STREET
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-282-8820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0431632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000737107EMedicaid
GAP00298084OtherRAILROAD MEDICARE
GA581177261AOtherMEDICARE GRP PROV #
GA000737107NMedicaid
GA581177261AOtherMEDICARE GRP PROV #