Provider Demographics
NPI:1497799415
Name:BALDASSARI, ELMO WILLIAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:ELMO
Middle Name:WILLIAM
Last Name:BALDASSARI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 MONROE AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2497
Mailing Address - Country:US
Mailing Address - Phone:570-963-1974
Mailing Address - Fax:570-963-0762
Practice Address - Street 1:1439 MONROE AVE STE 3
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18509-2497
Practice Address - Country:US
Practice Address - Phone:570-963-1974
Practice Address - Fax:570-963-0762
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003666L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA480024264OtherRAILROAD MEDICARE
PA0016528000002Medicaid
PAU65985Medicare UPIN