Provider Demographics
NPI:1437154432
Name:BALLESTEROS, JAIME T (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:T
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:G3239 BEECHER RD
Mailing Address - Street 2:STE C
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3616
Mailing Address - Country:US
Mailing Address - Phone:810-732-9222
Mailing Address - Fax:810-732-4344
Practice Address - Street 1:G3239 BEECHER RD
Practice Address - Street 2:STE C
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3616
Practice Address - Country:US
Practice Address - Phone:810-732-9222
Practice Address - Fax:810-732-4344
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046964174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4211863Medicaid
MI4211863Medicaid
MIE49596Medicare UPIN