Provider Demographics
NPI:1598057473
Name:LAVERTY BALLESTEROS, CYNTHIA (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:LAVERTY BALLESTEROS
Suffix:
Gender:F
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 9101
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-9494
Mailing Address - Country:US
Mailing Address - Phone:940-383-2700
Mailing Address - Fax:940-383-7640
Practice Address - Street 1:3751 S I 35 E
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6852
Practice Address - Country:US
Practice Address - Phone:940-383-2700
Practice Address - Fax:940-383-7640
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01081615A207Q00000X
NC2019-00095207Q00000X
VA0101266203207Q00000X
TXQ3223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine