1306435524 NPI number — DEBORAH ANN BALTAZAR-MOORE LMT

Table of content: DEBORAH ANN BALTAZAR-MOORE LMT (NPI 1306435524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306435524 NPI number — DEBORAH ANN BALTAZAR-MOORE LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALTAZAR-MOORE
Provider First Name:
DEBORAH
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306435524
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3145 DALE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92104-4509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-519-9424
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8555 AERO DR STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-1744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-542-0884
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  75678 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com