1851389076 NPI number — DR. CHARLES FREDERICK BALBUENA HEATH M.D.

Table of content: DR. CHARLES FREDERICK BALBUENA HEATH M.D. (NPI 1851389076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851389076 NPI number — DR. CHARLES FREDERICK BALBUENA HEATH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALBUENA HEATH
Provider First Name:
CHARLES
Provider Middle Name:
FREDERICK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1851389076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1302 RIVER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALATKA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32177-5042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-328-0108
Provider Business Mailing Address Fax Number:
386-325-1086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 N ORANGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN COVE SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32043-2547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-644-1472
Provider Business Practice Location Address Fax Number:
866-412-8287
Provider Enumeration Date:
10/11/2005

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: 208D00000X , with the licence number:  16184 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 113312200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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