Healthcare Provider Details

I. General information

NPI: 1013900802
Provider Name (Legal Business Name): ISTVAN BALOG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 GA HWY 57 BETWEEN 1-95 AND HWY 17 @ EULONIA
TOWNSEND GA
31331-8128
US

IV. Provider business mailing address

147 BELLE POINT PKWY
BRUNSWICK GA
31525-2174
US

V. Phone/Fax

Practice location:
  • Phone: 912-832-4495
  • Fax: 912-832-4852
Mailing address:
  • Phone: 912-466-0766
  • Fax: 912-832-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number025524
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: