1598981698 NPI number — DR. WASSIM BALLAN MD

Table of content: DR. WASSIM BALLAN MD (NPI 1598981698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598981698 NPI number — DR. WASSIM BALLAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLAN
Provider First Name:
WASSIM
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1598981698
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8022
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85246-8022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-636-1149
Provider Business Mailing Address Fax Number:
480-452-0998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 E THOMAS RD
Provider Second Line Business Practice Location Address:
INFECTION CONTROL OFFICE
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016-7710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-667-4438
Provider Business Practice Location Address Fax Number:
602-546-0834
Provider Enumeration Date:
04/17/2007

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: 208000000X , with the licence number:  A85893 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 36477 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0208X , with the licence number: A85893 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0208X , with the licence number: 36477 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 36477 . This is a "AZ MEDICAL LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 230583-01 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: A85893 . This is a "CA MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".