Provider Demographics
NPI:1518180629
Name:BALESTRA, JESUS MANUEL
Entity Type:Individual
Prefix:DR
First Name:JESUS
Middle Name:MANUEL
Last Name:BALESTRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 67 100
Mailing Address - Street 2:MANSIONES DE SIERRA TAINA
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956
Mailing Address - Country:US
Mailing Address - Phone:787-786-7678
Mailing Address - Fax:
Practice Address - Street 1:100 AVE LAUREL
Practice Address - Street 2:URB SANTA JUANITA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-4816
Practice Address - Country:US
Practice Address - Phone:787-786-6165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5014208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5014OtherLICENSE NUMBER