Provider Demographics
NPI:1184679151
Name:BALLELOS, EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:BALLELOS
Suffix:
Gender:M
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:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4488
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:4101 TOWN CTR BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-5846
Practice Address - Country:US
Practice Address - Phone:407-850-3497
Practice Address - Fax:407-851-0421
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076442174400000X
FLME76442208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008475100Medicaid
H04915Medicare UPIN