Provider Demographics
NPI:1497957815
Name:BALLESTEROS, ALFONSO G (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:G
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 1:14420 W MEEKER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-5288
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14416 W MEEKER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85375-5284
Practice Address - Country:US
Practice Address - Phone:623-285-2780
Practice Address - Fax:623-285-2728
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2930208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AL349OtherBLUECROSS BLUESHIELD OF TEXAS
TX205004901Medicaid
8L16737Medicare PIN