Basic Information
Provider Information
NPI: 1003138975
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BALID
FirstName: GERARDO
MiddleName: TEMPORAL
NamePrefix: MR.
NameSuffix: JR.
Credential: P.T
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 8115 255TH ST
Address2:  
City: GLEN OAKS
State: NY
PostalCode: 110041414
CountryCode: US
TelephoneNumber: 7183433112
FaxNumber: 7183433112
Practice Location
Address1: 8115 255TH ST
Address2:  
City: GLEN OAKS
State: NY
PostalCode: 110041414
CountryCode: US
TelephoneNumber: 7183433112
FaxNumber: 7183433112
Other Information
ProviderEnumerationDate: 02/19/2010
LastUpdateDate: 02/19/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X024448NYY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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