Basic Information
Provider Information | |||||||||
NPI: | 1598967374 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BALLESTER | ||||||||
FirstName: | GABRIELA | ||||||||
MiddleName: | V. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 100278 | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 326100278 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3522737832 | ||||||||
FaxNumber: | 3522736867 | ||||||||
Practice Location | |||||||||
Address1: | 1204 N VERCLER RD | ||||||||
Address2: |   | ||||||||
City: | SPOKANE VALLEY | ||||||||
State: | WA | ||||||||
PostalCode: | 992161020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5092281000 | ||||||||
FaxNumber: | 5092529300 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2007 | ||||||||
LastUpdateDate: | 07/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | ME140817 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0000X | MD 15560 | RI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0000X | 35.145343 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0000X | MD61181565 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology |
ID Information
ID | Type | State | Issuer | Description | P01559044 | 01 | NY | RAILROAD MEDICARE | OTHER | 105073800 | 05 | FL |   | MEDICAID | 278318 | 05 | OH |   | MEDICAID | 1598967374 | 05 | WA |   | MEDICAID |