Provider Demographics
NPI:1457344715
Name:BALDERRAMA, JAIME A (MD)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:A
Last Name:BALDERRAMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:ALFREDO
Other - Last Name:BALDERRAMA RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4524 N MARYVALE PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-1730
Mailing Address - Country:US
Mailing Address - Phone:623-845-9009
Mailing Address - Fax:623-845-6933
Practice Address - Street 1:4524 N MARYVALE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1730
Practice Address - Country:US
Practice Address - Phone:623-845-9009
Practice Address - Fax:623-845-6933
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17010208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ270926Medicaid
AZE00838Medicare UPIN