Provider Demographics
NPI:1972038461
Name:BALTAZAR, DAVID ABRAHAM (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ABRAHAM
Last Name:BALTAZAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13943 N 91ST AVE STE C101
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3688
Mailing Address - Country:US
Mailing Address - Phone:623-972-3992
Mailing Address - Fax:
Practice Address - Street 1:13943 N 91ST AVE STE C101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3688
Practice Address - Country:US
Practice Address - Phone:623-972-3992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-22
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ010194207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology