Healthcare Provider Details

I. General information

NPI: 1285657486
Provider Name (Legal Business Name): ELISSA R BALLAS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48TH MDG/RAF LAKENHEATH
APO AE
09461
US

IV. Provider business mailing address

48TH MDG/RAF LAKENHEATH
APO AE
09461
US

V. Phone/Fax

Practice location:
  • Phone: 16-385-2801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2242
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MB13211900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: