Provider Demographics
NPI:1376537050
Name:BALENTINE, JERRY RAY JR (DO)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:RAY
Last Name:BALENTINE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 GRACE CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:RYE
Mailing Address - State:NY
Mailing Address - Zip Code:10580-4217
Mailing Address - Country:US
Mailing Address - Phone:718-960-6371
Mailing Address - Fax:
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:ST.BARNABAS HOSPITAL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2545
Practice Address - Country:US
Practice Address - Phone:718-960-6371
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181012207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF34896Medicare UPIN
74K521Medicare ID - Type Unspecified