Provider Demographics
NPI:1861645525
Name:BALLESTAS, EDUARDO (MD)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:
Last Name:BALLESTAS
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 1:3165 SPOONBILL CT.
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762
Mailing Address - Country:US
Mailing Address - Phone:727-422-4063
Mailing Address - Fax:
Practice Address - Street 1:1850 NW 9TH AVE
Practice Address - Street 2:RYDER TRAUMA T242
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136
Practice Address - Country:US
Practice Address - Phone:305-585-1280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 117835174400000X
FLTRN10743390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program