Provider Demographics
NPI:1871525337
Name:BALDERSTON, KEITH DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:DOUGLAS
Last Name:BALDERSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:541-485-2777
Mailing Address - Fax:541-246-2353
Practice Address - Street 1:3355 RIVERBEND DR
Practice Address - Street 2:STE 210
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8800
Practice Address - Country:US
Practice Address - Phone:541-485-2777
Practice Address - Fax:541-246-2353
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18230207VM0101X
IDM-13818207VM0101X
WAMD60748459207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067731Medicaid
R0000WCJNMMedicare PIN
OR113269Medicare ID - Type Unspecified