Basic Information
| Provider Information | |||||||||
| NPI: | 1861665945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALTODANO | ||||||||
| FirstName: | JUAN DIEGO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BALTODANO PARRA | ||||||||
| OtherFirstName: | JUAN DIEGO | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2369 STAPLES MILL RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232302909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042858206 | ||||||||
| FaxNumber: | 8042858332 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 WADSWORTH DR | ||||||||
| Address2: | |||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232364510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042891131 | ||||||||
| FaxNumber: | 8043203102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2008 | ||||||||
| LastUpdateDate: | 04/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 0101243367 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1861665945 | 05 | VA | MEDICAID |