Provider Demographics
NPI:1053611384
Name:RAUL S BALAGTAS MD PA
Entity type:Organization
Organization Name:RAUL S BALAGTAS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:BALAGTAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-964-3050
Mailing Address - Street 1:PO BOX 130009
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33681-0009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10330 N DALE MABRY HWY STE 201
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-4404
Practice Address - Country:US
Practice Address - Phone:813-961-6633
Practice Address - Fax:813-961-7733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0059469174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEE249AMedicare PIN