Provider Demographics
NPI:1861665945
Name:BALTODANO, JUAN DIEGO (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN DIEGO
Middle Name:
Last Name:BALTODANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JUAN DIEGO
Other - Middle Name:
Other - Last Name:BALTODANO PARRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2369 STAPLES MILL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-2909
Mailing Address - Country:US
Mailing Address - Phone:804-285-8206
Mailing Address - Fax:804-285-8332
Practice Address - Street 1:201 WADSWORTH DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-4510
Practice Address - Country:US
Practice Address - Phone:804-289-1131
Practice Address - Fax:804-320-3102
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243367207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1861665945Medicaid
VA1861665945Medicaid
VAVV9184BMedicare PIN
VAVV9184CMedicare PIN