Provider Demographics
NPI:1932110137
Name:DANA BALDERRAMA MD PC
Entity Type:Organization
Organization Name:DANA BALDERRAMA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BALDERRAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-453-9487
Mailing Address - Street 1:1945 MESQUITE AVE STE D
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5889
Mailing Address - Country:US
Mailing Address - Phone:928-453-9487
Mailing Address - Fax:928-453-9562
Practice Address - Street 1:1945 MESQUITE AVE STE D
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5889
Practice Address - Country:US
Practice Address - Phone:928-453-9487
Practice Address - Fax:928-453-9562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZI03755Medicare UPIN
AZZ112564Medicare PIN