Healthcare Provider Details

I. General information

NPI: 1265460646
Provider Name (Legal Business Name): ROBERT C BALOGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 W GORE
LAWTON OK
73505
US

IV. Provider business mailing address

PO BOX 785
LAWTON OK
73502
US

V. Phone/Fax

Practice location:
  • Phone: 580-510-7037
  • Fax: 580-510-7038
Mailing address:
  • Phone: 580-357-9984
  • Fax: 580-357-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number45039
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number102704
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25362
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: