Healthcare Provider Details

I. General information

NPI: 1992458822
Provider Name (Legal Business Name): WASSIM BALLAN MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 02/01/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS ROAD INFECTION CONTROL DEPT - PCH
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

PO BOX 8022
CHANDLER AZ
85246-8022
US

V. Phone/Fax

Practice location:
  • Phone: 480-636-1149
  • Fax: 214-383-8360
Mailing address:
  • Phone: 214-383-8360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number
License Number State

VIII. Authorized Official

Name: WASSIM BALLAN
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 415-317-1304