Provider Demographics
NPI:1871667048
Name:BALLESTAS, CARMEN S (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:S
Last Name:BALLESTAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:1150 N 35TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021
Practice Address - Country:US
Practice Address - Phone:954-265-2234
Practice Address - Fax:954-985-2288
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2021-03-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME1109362080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004186500Medicaid