Provider Demographics
NPI:1205978921
Name:BALLEZA, MARIA (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:
Last Name:BALLEZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9631 MERRIMAN RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150
Mailing Address - Country:US
Mailing Address - Phone:734-261-7798
Mailing Address - Fax:
Practice Address - Street 1:27115 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-2900
Practice Address - Country:US
Practice Address - Phone:586-776-7000
Practice Address - Fax:586-776-2310
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301049546207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP19030004Medicare ID - Type Unspecified