=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750488326
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANAISYS M. BALLESTEROS, D.O., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9290 SW 72ND ST SUITE 105
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-275-6202
-----------------------------------------------------
Fax | 305-275-6203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9290 SW 72ND ST SUITE 105
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-275-6202
-----------------------------------------------------
Fax | 305-275-6203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ANAISYS MARIA BALLESTEROS
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 305-275-6202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS8354
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------