Provider Demographics
NPI:1639443534
Name:JEROEN BALLEDUX MD LLC
Entity Type:Organization
Organization Name:JEROEN BALLEDUX MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONAL PRACTICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANJALI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORJANI
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:561-844-0120
Mailing Address - Street 1:1447 MEDICAL PARK BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3164
Mailing Address - Country:US
Mailing Address - Phone:561-844-0120
Mailing Address - Fax:561-800-1074
Practice Address - Street 1:1447 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3164
Practice Address - Country:US
Practice Address - Phone:561-844-0120
Practice Address - Fax:561-800-1074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109148208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty