Healthcare Provider Details

I. General information

NPI: 1518710102
Provider Name (Legal Business Name): NELSON MARTINEZ MERIZALDE BALAREZO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 01/27/2025
Certification Date:
Deactivation Date: 11/22/2024
Reactivation Date: 01/27/2025

III. Provider practice location address

110 IRVING ST. NW DEPT OF INTERNAL MEDICINE
WASHINGTON DC
20010
US

IV. Provider business mailing address

264 RAMIREZ PENA AVENUE
LIMA LIMA
15101
PE

V. Phone/Fax

Practice location:
  • Phone: 202-877-8271
  • Fax: 202-877-6292
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: