Provider Demographics
NPI:1346416542
Name:WF BALLESTEROS MD
Entity Type:Organization
Organization Name:WF BALLESTEROS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WELLINGTON
Authorized Official - Middle Name:F
Authorized Official - Last Name:BALLESTEROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-697-1562
Mailing Address - Street 1:3901 FAIRWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-1428
Mailing Address - Country:US
Mailing Address - Phone:432-697-1562
Mailing Address - Fax:432-699-3801
Practice Address - Street 1:3901 FAIRWOOD CT
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-1428
Practice Address - Country:US
Practice Address - Phone:432-697-1562
Practice Address - Fax:432-699-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6770208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00B18XOtherBLUE CROSS BLUE SHEILD
TX130229103Medicaid