Provider Demographics
NPI:1649254749
Name:BALBUENA, LUIS JR (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:BALBUENA
Suffix:JR
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 1325
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1325
Mailing Address - Country:US
Mailing Address - Phone:903-927-6880
Mailing Address - Fax:903-927-6884
Practice Address - Street 1:703 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-5337
Practice Address - Country:US
Practice Address - Phone:903-927-6880
Practice Address - Fax:903-927-6884
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5538207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041854301Medicaid
TX041854301Medicaid
8313K1Medicare ID - Type Unspecified