Provider Demographics
NPI:1063671683
Name:MEDICAL PAVILION CLINC
Entity Type:Organization
Organization Name:MEDICAL PAVILION CLINC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR - OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:BALLESTAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-629-9190
Mailing Address - Street 1:2525 HARBOR BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5317
Mailing Address - Country:US
Mailing Address - Phone:941-629-9190
Mailing Address - Fax:941-625-2751
Practice Address - Street 1:2525 HARBOR BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5317
Practice Address - Country:US
Practice Address - Phone:941-629-9190
Practice Address - Fax:941-625-2751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0044391305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0608916500Medicaid