Provider Demographics
NPI:1578654448
Name:CEBALLOS, RODOLFO BAURA (MD)
Entity Type:Individual
Prefix:MR
First Name:RODOLFO
Middle Name:BAURA
Last Name:CEBALLOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1122 CULBERT DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4212
Mailing Address - Country:US
Mailing Address - Phone:276-783-7914
Mailing Address - Fax:276-783-1882
Practice Address - Street 1:1122 CULBERT DRIVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4212
Practice Address - Country:US
Practice Address - Phone:276-783-7914
Practice Address - Fax:276-783-1882
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101024299208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA062952OtherANTHEM
B61477Medicare UPIN