Provider Demographics
NPI:1851350029
Name:BALTA, VICTOR A (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:A
Last Name:BALTA
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 1:4000 N HIGHWAY A1A PH 2
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34949-8530
Mailing Address - Country:US
Mailing Address - Phone:772-359-9529
Mailing Address - Fax:
Practice Address - Street 1:4000 N HIGHWAY A1A PH 2
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34949-8530
Practice Address - Country:US
Practice Address - Phone:772-359-9529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 830272084P0800X
FLME83027207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265998100Medicaid
FL62795OtherBLUE CROSS
FL62795OtherBLUE CROSS
FL62795XMedicare ID - Type Unspecified