Provider Demographics
NPI:1134121064
Name:BALAREZO, FABIOLA SARA (MD)
Entity Type:Individual
Prefix:DR
First Name:FABIOLA
Middle Name:SARA
Last Name:BALAREZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FABIOLA
Other - Middle Name:BALAREZO
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:99 EAST RIVER DRIVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-7301
Mailing Address - Country:US
Mailing Address - Phone:860-282-4128
Mailing Address - Fax:860-282-0170
Practice Address - Street 1:2 TRAP FALLS ROAD
Practice Address - Street 2:SUITE 414
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-7354
Practice Address - Country:US
Practice Address - Phone:203-929-7353
Practice Address - Fax:203-929-0756
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037679207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001376799Medicaid
CT220000533Medicare ID - Type Unspecified
CT001376799Medicaid