MEDICARE: MILDRED BALUYOT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	111547	MO

General Provider Information

NPI Number	:	1144226176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MILDRED BALUYOT MD

Provider Business Mailing Address
First Line	:	1300 E BRADFORD PKWY
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-4264
Country	:	US
Telephone Number	:	417-269-5400
Fax Number	:	417-269-7212

Provider Business Practice Location Address
First Line	:	1300 E BRADFORD PKWY
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-4264
Country	:	US
Telephone Number	:	417-269-5400
Fax Number	:	417-269-7212

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	07/08/2007

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