Provider Demographics
NPI:1548580624
Name:BALASTA, PERPEMELO III (DO)
Entity Type:Individual
Prefix:
First Name:PERPEMELO
Middle Name:
Last Name:BALASTA
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4480 UTICA RIDGE RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722
Mailing Address - Country:US
Mailing Address - Phone:563-742-4850
Mailing Address - Fax:563-742-4855
Practice Address - Street 1:55497 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:THERMAL
Practice Address - State:CA
Practice Address - Zip Code:92274-9412
Practice Address - Country:US
Practice Address - Phone:760-399-4526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13544207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine