Healthcare Provider Details

I. General information

NPI: 1205064581
Provider Name (Legal Business Name): BRIAN ANTHONY BALTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W DREW AVE
MONETTE AR
72447-9010
US

IV. Provider business mailing address

210 W DREW AVE PO BOX 747
MONETTE AR
72447-9010
US

V. Phone/Fax

Practice location:
  • Phone: 870-486-5464
  • Fax: 870-486-1211
Mailing address:
  • Phone: 870-486-5464
  • Fax: 870-486-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE7150
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: