=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033120647
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA DE LOS ANGELES BALZAC M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | VA CARIBBEAN HEALTH CENTER -PSYCH DEPT. 10 CASIA ST.
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00921-3201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-758-7575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HACIENDA REAL #253 LLUVIA DE CORAL ST.
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-769-9903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 12626
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------