Provider Demographics
NPI:1639169154
Name:BALDERAS, RAQUEL (MD)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:BALDERAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:642 DAMERON DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2411
Mailing Address - Country:US
Mailing Address - Phone:928-445-5211
Mailing Address - Fax:928-776-8484
Practice Address - Street 1:3345 N WINDSONG DR
Practice Address - Street 2:WINDSONG CENTER
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2283
Practice Address - Country:US
Practice Address - Phone:928-445-5211
Practice Address - Fax:928-776-8484
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ323372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
G79213Medicare UPIN