Healthcare Provider Details

I. General information

NPI: 1851404545
Provider Name (Legal Business Name): MANUEL BALDERAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MALL RD
BURLINGTON MA
01805-3509
US

IV. Provider business mailing address

6031 WOOD PASS
SAN ANTONIO TX
78249-1922
US

V. Phone/Fax

Practice location:
  • Phone: 781-744-8000
  • Fax:
Mailing address:
  • Phone: 210-617-5130
  • Fax: 210-617-5178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberL0011
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberL0011
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number263953
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: