Provider Demographics
NPI:1851404545
Name:BALDERAS, MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:BALDERAS
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 1:6031 WOOD PASS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-1922
Mailing Address - Country:US
Mailing Address - Phone:210-617-5130
Mailing Address - Fax:210-617-5178
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-3509
Practice Address - Country:US
Practice Address - Phone:781-744-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL00112084A0401X, 2084P0802X
MA2639532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
1408884-02OtherTPI
8980J7Medicare ID - Type Unspecified
H31639Medicare UPIN