Provider Demographics
NPI:1346205788
Name:BALES, MITZI M (MD)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:M
Last Name:BALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MITZI
Other - Middle Name:MARIE
Other - Last Name:BALES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2117 KEYSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-8749
Mailing Address - Country:US
Mailing Address - Phone:316-733-5120
Mailing Address - Fax:316-733-1280
Practice Address - Street 1:2117 KEYSTONE CIR
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-8749
Practice Address - Country:US
Practice Address - Phone:316-733-5120
Practice Address - Fax:316-733-1280
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-26016207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
003719194OtherMEDICARE
KS100282210CMedicaid
003719194OtherMEDICARE