Basic Information
Provider Information
NPI: 1003141847
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BALSAMO
FirstName: DALIA
MiddleName: N
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3125 MYERS ST
Address2:  
City: RIVERSIDE
State: CA
PostalCode: 925035527
CountryCode: US
TelephoneNumber: 9513584840
FaxNumber:  
Practice Location
Address1: 3125 MYERS ST
Address2:  
City: RIVERSIDE
State: CA
PostalCode: 925035527
CountryCode: US
TelephoneNumber: 9513584840
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/13/2009
LastUpdateDate: 09/28/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2084F0202XA142906CAN Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
2084P0800XA142906CAN Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
2084P0804XA142906CAY Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry

No ID Information.


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