Basic Information
| Provider Information | |||||||||
| NPI: | 1669426094 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALOTESCU | ||||||||
| FirstName: | RAZVAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 WINKLER AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 228 PONTE VEDRA PARK DR STE 500 | ||||||||
| Address2: | |||||||||
| City: | PONTE VEDRA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320826611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042731180 | ||||||||
| FaxNumber: | 9042736116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 08/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 001581 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME99489 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00025874503 | 01 | NY | UNIVERA | OTHER | 000526685002 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER | 02342363 | 05 | NY | MEDICAID | 0411353 | 01 | NY | INDEPENDENT HEALTH | OTHER |