Provider Demographics
NPI:1609969419
Name:BALLESTAS, DAVID S (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:BALLESTAS
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 1:2525 HARBOR BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952
Mailing Address - Country:US
Mailing Address - Phone:941-629-7593
Mailing Address - Fax:941-625-2751
Practice Address - Street 1:2525 HARBOR BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952
Practice Address - Country:US
Practice Address - Phone:941-629-7593
Practice Address - Fax:941-625-2751
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0044391207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068916500Medicaid
FL068916500Medicaid
FL08137ZMedicare PIN
D84985Medicare UPIN