Provider Demographics
NPI:1255587010
Name:BALCH, CAYLI NGUYEN (DO)
Entity type:Individual
Prefix:DR
First Name:CAYLI
Middle Name:NGUYEN
Last Name:BALCH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:CAYLI
Other - Middle Name:TAM
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4319 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3893
Mailing Address - Country:US
Mailing Address - Phone:817-984-6210
Mailing Address - Fax:817-984-6216
Practice Address - Street 1:4319 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-984-6210
Practice Address - Fax:817-984-6216
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3942208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX331318-01Medicaid
TX298928YRRNMedicare PIN