Provider Demographics
NPI:1558358366
Name:BALAGTAS, RAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:
Last Name:BALAGTAS
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 130009
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33681-0009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10330 N DALE MABRY HWY STE 201
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-4404
Practice Address - Country:US
Practice Address - Phone:813-961-6633
Practice Address - Fax:813-961-7733
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0059469174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14875XMedicare PIN
F25663Medicare UPIN