Provider Demographics
NPI:1104931542
Name:BALFOUR, GLENN MARK (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:MARK
Last Name:BALFOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5520 LOS ROBLES DR
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-4424
Mailing Address - Country:US
Mailing Address - Phone:760-845-8884
Mailing Address - Fax:442-500-8681
Practice Address - Street 1:785 GRAND AVE STE 218
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2371
Practice Address - Country:US
Practice Address - Phone:442-500-8851
Practice Address - Fax:442-500-8681
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA866322081P0004X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABF428ZOtherMEDICARE PTAN