Healthcare Provider Details

I. General information

NPI: 1043357262
Provider Name (Legal Business Name): CHARLES HUNT BALLARD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12742 LIMONITE AVE
EASTVALE CA
92880-9630
US

IV. Provider business mailing address

12742 LIMONITE AVE
EASTVALE CA
92880-9630
US

V. Phone/Fax

Practice location:
  • Phone: 951-739-2712
  • Fax:
Mailing address:
  • Phone: 951-739-2712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDOS735
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A10039
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: