Basic Information
| Provider Information | |||||||||
| NPI: | 1477532943 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALMADRID | ||||||||
| FirstName: | LUZ | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 E HIGHLAND DR | ||||||||
| Address2: | |||||||||
| City: | OCONTO FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541541002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208463092 | ||||||||
| FaxNumber: | 9208468313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33603-020 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1326349135 | 01 | WI | CMH SB NPI | OTHER | 1851477913 | 01 | WI | CMH NPI | OTHER | 1467583096 | 01 | WI | CMH PCC OF NPI | OTHER | 31872600 | 05 | WI | MEDICAID |