Provider Demographics
NPI:1699039362
Name:BALBUENA MERLE, RAISA IDELISS (MD)
Entity type:Individual
Prefix:DR
First Name:RAISA
Middle Name:IDELISS
Last Name:BALBUENA MERLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CEDAR ST
Mailing Address - Street 2:YNHH LABORATORY MEDICINE
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-2355
Mailing Address - Country:US
Mailing Address - Phone:203-688-2446
Mailing Address - Fax:
Practice Address - Street 1:33 CEDAR ST
Practice Address - Street 2:YNHH LABORATORY MEDICINE
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-2355
Practice Address - Country:US
Practice Address - Phone:203-688-2446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT61662207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology