Healthcare Provider Details

I. General information

NPI: 1033672712
Provider Name (Legal Business Name): MATIAS BALLESTEROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3708 MOUNTAIN RD
PASADENA MD
21122-2025
US

IV. Provider business mailing address

9166 LANDON HOUSE LN
FREDERICK MD
21704-7763
US

V. Phone/Fax

Practice location:
  • Phone: 410-553-8273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD95030
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: