Provider Demographics
NPI:1174668271
Name:BALLESTEROS, ANAISYS M (DO)
Entity Type:Individual
Prefix:
First Name:ANAISYS
Middle Name:M
Last Name:BALLESTEROS
Suffix:
Gender:F
Credentials:DO
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 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-3236
Mailing Address - Country:US
Mailing Address - Phone:786-243-8444
Mailing Address - Fax:
Practice Address - Street 1:975 BAPTIST WAY STE 202
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-7600
Practice Address - Country:US
Practice Address - Phone:786-243-8444
Practice Address - Fax:786-576-0416
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47852OtherBCBS PROVIDER NO.
FL265016900Medicaid
FLH63657Medicare UPIN
FL47852OtherBCBS PROVIDER NO.
FLK6234Medicare ID - Type UnspecifiedMEDICARE GROUP NO.