Provider Demographics
NPI:1083695746
Name:BALLESTEROS, WELLINGTON F (MD)
Entity type:Individual
Prefix:DR
First Name:WELLINGTON
Middle Name:F
Last Name:BALLESTEROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5576
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79704-5576
Mailing Address - Country:US
Mailing Address - Phone:432-697-4747
Mailing Address - Fax:
Practice Address - Street 1:2500 DELANO AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6357
Practice Address - Country:US
Practice Address - Phone:432-697-4747
Practice Address - Fax:432-699-3813
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6770208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130229107Medicaid
TX130229107Medicaid
8B5500Medicare ID - Type Unspecified