Provider Demographics
NPI:1164626768
Name:BALBASTRO, JEEATHBELL NONESUPPLIED (MD)
Entity Type:Individual
Prefix:DR
First Name:JEEATHBELL
Middle Name:NONESUPPLIED
Last Name:BALBASTRO
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 1:500 TIKI DR APT 204
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77554-7152
Mailing Address - Country:US
Mailing Address - Phone:409-763-4135
Mailing Address - Fax:
Practice Address - Street 1:500 TIKI DR APT 204
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77554-7152
Practice Address - Country:US
Practice Address - Phone:409-763-4135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10019928207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2587002690OtherMYUTMB 2587002690-COMMERCIAL NUMBER