Basic Information
| Provider Information | |||||||||
| NPI: | 1063440667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALTAZAR | ||||||||
| FirstName: | ROMEO | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | BALTAZAR | ||||||||
| OtherFirstName: | ROMEO | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13601 PRESTON ROAD | ||||||||
| Address2: | #1000W | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155007 | ||||||||
| FaxNumber: | 9727155682 | ||||||||
| Practice Location | |||||||||
| Address1: | 13601 PRESTON ROAD | ||||||||
| Address2: | #1000W | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155007 | ||||||||
| FaxNumber: | 9727155682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 11/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G7781 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 8AB552 | 01 | BCBS | OTHER | 098626702 | 05 | TX | MEDICAID | G7781 | 01 | TSBME LIC | OTHER |