Provider Demographics
NPI:1487861258
Name:BALESTINO, GLENN ANTHONY (IDC)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:ANTHONY
Last Name:BALESTINO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 GREENELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23701-2020
Mailing Address - Country:US
Mailing Address - Phone:757-445-6029
Mailing Address - Fax:
Practice Address - Street 1:USS VELLA GULF
Practice Address - Street 2:CG 72
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09590-1192
Practice Address - Country:US
Practice Address - Phone:757-444-9922
Practice Address - Fax:757-444-9922
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman