Provider Demographics
NPI:1659358588
Name:BALLESTER, PEDRO A (MD)
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:A
Last Name:BALLESTER
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 1:1405 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-6609
Mailing Address - Country:US
Mailing Address - Phone:330-373-1635
Mailing Address - Fax:330-392-8443
Practice Address - Street 1:1405 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6609
Practice Address - Country:US
Practice Address - Phone:330-373-1635
Practice Address - Fax:330-392-8443
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058499207P00000X
OH35058499B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0776414Medicaid
0664427Medicare ID - Type Unspecified
OH0776414Medicaid