Provider Demographics
NPI:1558700864
Name:BALTAZAR, TONY
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:
Last Name:BALTAZAR
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 1:19401 SAWYER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3329
Mailing Address - Country:US
Mailing Address - Phone:323-807-4691
Mailing Address - Fax:310-945-3356
Practice Address - Street 1:4733 W SUNSET BLVD FL 3
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6021
Practice Address - Country:US
Practice Address - Phone:323-807-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2023-09-26
Deactivation Date:2023-03-22
Deactivation Code:
Reactivation Date:2023-03-28
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program