Provider Demographics
NPI:1699835843
Name:BALDERAS, DAGOBERTO (DO)
Entity type:Individual
Prefix:DR
First Name:DAGOBERTO
Middle Name:
Last Name:BALDERAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5424 W HIGHWAY 290
Mailing Address - Street 2:STE 101
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8827
Mailing Address - Country:US
Mailing Address - Phone:512-643-4400
Mailing Address - Fax:
Practice Address - Street 1:5424 W HIGHWAY 290
Practice Address - Street 2:STE 101
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8827
Practice Address - Country:US
Practice Address - Phone:512-643-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10027209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345348YWFEMedicare UPIN