Healthcare Provider Details

I. General information

NPI: 1275720682
Provider Name (Legal Business Name): ELIZABETH ANDREA BALES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2007
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3226 BROAD ST
NEWPORT BEACH CA
92663-4224
US

IV. Provider business mailing address

3226 BROAD ST
NEWPORT BEACH CA
92663-4224
US

V. Phone/Fax

Practice location:
  • Phone: 949-410-4207
  • Fax:
Mailing address:
  • Phone: 949-410-4207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberA91889
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA91889
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: