Healthcare Provider Details

I. General information

NPI: 1932110137
Provider Name (Legal Business Name): DANA BALDERRAMA MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 MESQUITE AVE STE D
LAKE HAVASU CITY AZ
86403-5889
US

IV. Provider business mailing address

1945 MESQUITE AVE STE D
LAKE HAVASU CITY AZ
86403-5889
US

V. Phone/Fax

Practice location:
  • Phone: 928-453-9487
  • Fax: 928-453-9562
Mailing address:
  • Phone: 928-453-9487
  • Fax: 928-453-9562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DANA S BALDERRAMA
Title or Position: OWNER
Credential: MD
Phone: 928-453-9487