Provider Demographics
NPI:1194767160
Name:BALESTRERY, FRANK GEORGE (OD)
Entity type:Individual
Prefix:DR
First Name:FRANK
Middle Name:GEORGE
Last Name:BALESTRERY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8729 W ETCHEVERRY DR
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-8105
Mailing Address - Country:US
Mailing Address - Phone:209-835-8634
Mailing Address - Fax:
Practice Address - Street 1:4598 S TRACY BLVD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-8106
Practice Address - Country:US
Practice Address - Phone:209-835-1181
Practice Address - Fax:209-835-9396
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7720 TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0077200Medicaid
CASD0077200Medicaid
CA0794690001Medicare NSC
BV796ZMedicare PIN