Provider Demographics
NPI:1033120738
Name:BALTAZAR, OPHELIA (MD)
Entity Type:Individual
Prefix:DR
First Name:OPHELIA
Middle Name:
Last Name:BALTAZAR
Suffix:
Gender:F
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:PO BOX 216
Mailing Address - Street 2:
Mailing Address - City:JARRETTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21084-0216
Mailing Address - Country:US
Mailing Address - Phone:410-557-9322
Mailing Address - Fax:
Practice Address - Street 1:3805 NORRISVILLE RD
Practice Address - Street 2:
Practice Address - City:JARRETTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21084-1421
Practice Address - Country:US
Practice Address - Phone:410-557-9322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD187502080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine