Healthcare Provider Details

I. General information

NPI: 1861665945
Provider Name (Legal Business Name): JUAN DIEGO BALTODANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JUAN DIEGO BALTODANO PARRA M.D.

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 WADSWORTH DR
NORTH CHESTERFIELD VA
23236-4510
US

IV. Provider business mailing address

2369 STAPLES MILL RD SUITE 200
RICHMOND VA
23230-2909
US

V. Phone/Fax

Practice location:
  • Phone: 804-289-1131
  • Fax: 804-320-3102
Mailing address:
  • Phone: 804-285-8206
  • Fax: 804-285-8332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101243367
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: