Provider Demographics
NPI:1134176381
Name:BALUYOT, LESLIE CASTILLO (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:CASTILLO
Last Name:BALUYOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 FLORIDA AVE
Mailing Address - Street 2:#100
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4430
Mailing Address - Country:US
Mailing Address - Phone:209-577-5557
Mailing Address - Fax:209-577-8125
Practice Address - Street 1:1540 FLORIDA AVE
Practice Address - Street 2:#100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4430
Practice Address - Country:US
Practice Address - Phone:209-577-5557
Practice Address - Fax:209-577-8125
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77685207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ76734ZMedicaid
CAZZZ76734ZMedicaid
G56339Medicare UPIN