Provider Demographics
NPI:1154856375
Name:RODRIGUEZ BALLESTAS, ESTEFANIA (MD)
Entity Type:Individual
Prefix:
First Name:ESTEFANIA
Middle Name:
Last Name:RODRIGUEZ BALLESTAS
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 1:92 W MILLER ST FL 8
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2032
Mailing Address - Country:US
Mailing Address - Phone:321-841-7970
Mailing Address - Fax:321-841-7978
Practice Address - Street 1:92 W MILLER ST FL 8
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2032
Practice Address - Country:US
Practice Address - Phone:321-841-7970
Practice Address - Fax:321-841-7978
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME1619512080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118881200Medicaid