Healthcare Provider Details

I. General information

NPI: 1134121064
Provider Name (Legal Business Name): FABIOLA SARA BALAREZO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FABIOLA BALAREZO DIAZ M.D.

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 TRAP FALLS ROAD SUITE 414
SHELTON CT
06484-7354
US

IV. Provider business mailing address

99 EAST RIVER DRIVE 5TH FLOOR
EAST HARTFORD CT
06108-7301
US

V. Phone/Fax

Practice location:
  • Phone: 203-929-7353
  • Fax: 203-929-0756
Mailing address:
  • Phone: 860-282-4128
  • Fax: 860-282-0170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number037679
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: