Provider Demographics
NPI:1326266081
Name:BALLON-LANDA, GONZALO RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:RAFAEL
Last Name:BALLON-LANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4136 BACHMAN PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2028
Mailing Address - Country:US
Mailing Address - Phone:619-238-1443
Mailing Address - Fax:619-298-6188
Practice Address - Street 1:4136 BACHMAN PL
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2028
Practice Address - Country:US
Practice Address - Phone:619-238-1443
Practice Address - Fax:619-298-6188
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG41894207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G418940Medicaid
CAA48729Medicare UPIN
CAW11703Medicare ID - Type Unspecified