Provider Demographics
NPI:1164537064
Name:BALLESTERO, JULIANA
Entity Type:Individual
Prefix:
First Name:JULIANA
Middle Name:
Last Name:BALLESTERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10401 SPOTSYLVANIA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-8606
Mailing Address - Country:US
Mailing Address - Phone:540-361-1000
Mailing Address - Fax:
Practice Address - Street 1:736 BATTLEFIELD BLVD N
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4941
Practice Address - Country:US
Practice Address - Phone:757-312-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012342882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007248971Medicaid
VA001197 C88Medicare ID - Type Unspecified