Provider Demographics
NPI:1063440667
Name:BALTAZAR, ROMEO
Entity type:Individual
Prefix:
First Name:ROMEO
Middle Name:
Last Name:BALTAZAR
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:ROMEO
Other - Middle Name:C
Other - Last Name:BALTAZAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:13601 PRESTON ROAD
Mailing Address - Street 2:#1000W
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240
Mailing Address - Country:US
Mailing Address - Phone:972-715-5007
Mailing Address - Fax:972-715-5682
Practice Address - Street 1:13601 PRESTON ROAD
Practice Address - Street 2:#1000W
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240
Practice Address - Country:US
Practice Address - Phone:972-715-5007
Practice Address - Fax:972-715-5682
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7781207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
8AB552OtherBCBS
TX098626702Medicaid
G7781OtherTSBME LIC
8AB552OtherBCBS
G7781OtherTSBME LIC