Provider Demographics
NPI:1285991471
Name:BALTAZAR, CORY RUSSELL (DC)
Entity type:Individual
Prefix:DR
First Name:CORY
Middle Name:RUSSELL
Last Name:BALTAZAR
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43059 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2279
Mailing Address - Country:US
Mailing Address - Phone:734-891-5675
Mailing Address - Fax:
Practice Address - Street 1:43059 7 MILE RD
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-2279
Practice Address - Country:US
Practice Address - Phone:734-891-5675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009907111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor