Provider Demographics
NPI:1871647669
Name:BALDASARE, BRENT RALPH
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:RALPH
Last Name:BALDASARE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:779 N ALAFAYA TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7047
Mailing Address - Country:US
Mailing Address - Phone:407-381-4040
Mailing Address - Fax:321-234-9296
Practice Address - Street 1:779 N ALAFAYA TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7047
Practice Address - Country:US
Practice Address - Phone:407-381-4040
Practice Address - Fax:321-234-9296
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7682111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55910ZMedicare PIN
FLU86112Medicare UPIN