Healthcare Provider Details

I. General information

NPI: 1164537064
Provider Name (Legal Business Name): JULIANA BALLESTERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 BATTLEFIELD BLVD N
CHESAPEAKE VA
23320-4941
US

IV. Provider business mailing address

10401 SPOTSYLVANIA AVE STE 200
FREDERICKSBURG VA
22408-8606
US

V. Phone/Fax

Practice location:
  • Phone: 757-312-8121
  • Fax:
Mailing address:
  • Phone: 540-361-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101234288
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: