Provider Demographics
NPI:1508897216
Name:BALLESTEROS, MARTHA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:
Last Name:BALLESTEROS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SW 62ND AVE
Mailing Address - Street 2:RADIOLOGY DEPARTMENT
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3009
Mailing Address - Country:US
Mailing Address - Phone:305-662-8392
Mailing Address - Fax:305-667-8689
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:305-662-8392
Practice Address - Fax:305-667-8689
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN609602085N0700X, 2085P0229X
FLME719822085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257802600Medicaid