Provider Demographics
NPI:1972594497
Name:BALLESTEROS, ENRIQUE (MD)
Entity type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:
Last Name:BALLESTEROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HENRY
Other - Middle Name:
Other - Last Name:BALLESTEROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-3985
Practice Address - Country:US
Practice Address - Phone:860-679-2980
Practice Address - Fax:860-679-4334
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039969207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1972594497Medicaid
G95243Medicare UPIN
CT1972594497Medicaid