Provider Demographics
NPI:1093807117
Name:BALESTRERI, THOMAS M (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:BALESTRERI
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:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239-0189
Mailing Address - Country:US
Mailing Address - Phone:360-678-4071
Mailing Address - Fax:360-678-6014
Practice Address - Street 1:1211 24TH ST
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98233
Practice Address - Country:US
Practice Address - Phone:360-293-3181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035338207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1105717Medicaid
WA0123267OtherDLI
WA36350OtherREGENCE BS
G66613Medicare UPIN
WA1105717Medicaid