Provider Demographics
NPI:1770527269
Name:BALLESTEROS, JOSE VELOSO (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:VELOSO
Last Name:BALLESTEROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 SONOMA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4813
Mailing Address - Country:US
Mailing Address - Phone:707-527-8444
Mailing Address - Fax:707-636-2628
Practice Address - Street 1:990 SONOMA AVE STE 2
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4813
Practice Address - Country:US
Practice Address - Phone:707-527-8444
Practice Address - Fax:707-527-5327
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52195207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0065700Medicaid
CA00C521950Medicare ID - Type UnspecifiedPPIN