Healthcare Provider Details

I. General information

NPI: 1265446512
Provider Name (Legal Business Name): GARY A BALSTER MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2218 S PATTERSON BLVD
DAYTON OH
45409-1930
US

IV. Provider business mailing address

2218 S PATTERSON BLVD
DAYTON OH
45409-1930
US

V. Phone/Fax

Practice location:
  • Phone: 937-299-1918
  • Fax: 937-299-4832
Mailing address:
  • Phone: 937-299-1918
  • Fax: 937-299-4832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35051153
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number35051153
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35051153
License Number StateOH

VIII. Authorized Official

Name: DR. GARY ALLEN BALSTER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 937-299-1918