Provider Demographics
NPI:1427239078
Name:W BALLESTEROS LTD LLP
Entity type:Organization
Organization Name:W BALLESTEROS LTD LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WELLINGTON
Authorized Official - Middle Name:F
Authorized Official - Last Name:BALLESTEROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-413-9658
Mailing Address - Street 1:PO BOX 9849
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79708-9849
Mailing Address - Country:US
Mailing Address - Phone:432-697-1562
Mailing Address - Fax:432-688-7735
Practice Address - Street 1:5304 CASTLE PINE RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-3204
Practice Address - Country:US
Practice Address - Phone:432-697-1562
Practice Address - Fax:432-688-7735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6770208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130229108Medicaid
TX171584901Medicaid
TX0063RVOtherBLUE CROSS BLUE SHIELD
TX171584901Medicaid