Healthcare Provider Details

I. General information

NPI: 1134123474
Provider Name (Legal Business Name): KENNETH BALLAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 S BUENA VISTA ST STE. 215
BURBANK CA
91505-4554
US

IV. Provider business mailing address

777 FLOWER ST STE A
GLENDALE CA
91201-3000
US

V. Phone/Fax

Practice location:
  • Phone: 818-295-6944
  • Fax: 818-295-6948
Mailing address:
  • Phone: 818-637-2000
  • Fax: 818-242-8761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG29221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: