Provider Demographics
NPI:1619901592
Name:TORRES-BALTAZAR, EMMA V (MD)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:V
Last Name:TORRES-BALTAZAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:V
Other - Last Name:TORRES-BALTAZAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98611-0010
Mailing Address - Country:US
Mailing Address - Phone:360-274-4179
Mailing Address - Fax:360-274-8970
Practice Address - Street 1:606 SE ROAKE ST. / AVENUE
Practice Address - Street 2:CASTLE ROCK MEDICAL CLINIC
Practice Address - City:CASTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611
Practice Address - Country:US
Practice Address - Phone:360-274-4179
Practice Address - Fax:360-274-8970
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1219906Medicaid
WA20-3963995OtherTAX ID NUMBER
WA8858492Medicare PIN
WA1219906Medicaid