Provider Demographics
NPI:1548429954
Name:BALLEDUX, JEROEN PIETER (MD)
Entity Type:Individual
Prefix:
First Name:JEROEN
Middle Name:PIETER
Last Name:BALLEDUX
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:PO BOX 100744
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3196 S MARYLAND PKWY STE 425
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2318
Practice Address - Country:US
Practice Address - Phone:725-205-0725
Practice Address - Fax:725-204-5251
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86853208200000X
NV20150208200000X, 208200000X
CODR.0067447208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery