Basic Information
| Provider Information | |||||||||
| NPI: | 1275504581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALDASSARRI | ||||||||
| FirstName: | GERARDO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3162 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841103162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042021032 | ||||||||
| FaxNumber: | 9043764107 | ||||||||
| Practice Location | |||||||||
| Address1: | 98 NOCATEE VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | PONTE VEDRA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320816152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042024243 | ||||||||
| FaxNumber: | 9042024639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME92921 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 273061800 | 05 | FL | MEDICAID | 16636 | 01 | FL | BCBS | OTHER | 1275504581 | 01 | FL | TRICARE | OTHER |