MEDICARE: JEROEN PIETER BALLEDUX MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	86853	GA
2	208200000X	Plastic Surgery Physician	20150	NV

General Provider Information

NPI Number	:	1548429954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEROEN PIETER BALLEDUX MD

Provider Business Mailing Address
First Line	:	PO BOX 100744
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-0744
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3196 S MARYLAND PKWY STE 425
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-2318
Country	:	US
Telephone Number	:	725-205-0725
Fax Number	:	725-204-5251

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2008
Last Update Date	:	12/30/2022

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Directions to “ JEROEN PIETER BALLEDUX MD” Practice Location

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