Provider Demographics
NPI:1578658043
Name:BALENTINE, LARRY THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:THOMAS
Last Name:BALENTINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:LARRY
Other - Middle Name:
Other - Last Name:BALENTINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:259 HUNT RD
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98363-9657
Mailing Address - Country:US
Mailing Address - Phone:360-525-4646
Mailing Address - Fax:
Practice Address - Street 1:259 HUNT RD
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98363-9657
Practice Address - Country:US
Practice Address - Phone:360-525-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 60036029207RR0500X
WAMD60036029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR027313Medicaid
WA2205193Medicaid
WA0255846OtherSTATE L&I
WA0261345OtherSTATE L&I
WA0276454OtherSTATE L&I
WA8529216Medicaid
ORE87887Medicare UPIN
WA0276454OtherSTATE L&I
WAG8885634Medicare PIN
WAG8885036Medicare PIN
WA0253196OtherSTATE L&I
WAG8899599Medicare PIN
OR027313Medicaid