1205012127 NPI number — SAMUEL C BALLON MD FACOG FACS FRCSC A PROF CORPORATION

Table of content: (NPI 1205012127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205012127 NPI number — SAMUEL C BALLON MD FACOG FACS FRCSC A PROF CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMUEL C BALLON MD FACOG FACS FRCSC A PROF CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1205012127
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2504 SAMARITAN DR STE 20
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95124-4005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-356-3725
Provider Business Mailing Address Fax Number:
408-376-3713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2504 SAMARITAN DR STE 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95124-4005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-356-3725
Provider Business Practice Location Address Fax Number:
408-376-3713
Provider Enumeration Date:
01/10/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BALLON
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
408-356-3725

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G21751 , 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)