Provider Demographics
NPI:1275572372
Name:BALLESTEROS, DOUGLAS A (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:BALLESTEROS
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 1:1700 E WALNUT AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2605
Mailing Address - Country:US
Mailing Address - Phone:310-301-2030
Mailing Address - Fax:310-306-5247
Practice Address - Street 1:2400 E 4TH ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2026
Practice Address - Country:US
Practice Address - Phone:619-470-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74965207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA74965BMedicare PIN