Healthcare Provider Details

I. General information

NPI: 1063776466
Provider Name (Legal Business Name): MEGAN S BALLIET D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN E STATKEWICZ D.P.M.

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 PARNASSUS AVE # A-501
SAN FRANCISCO CA
94143-2202
US

IV. Provider business mailing address

20130 LAKE CHABOT RD STE 202
CASTRO VALLEY CA
94546-5340
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-2357
  • Fax:
Mailing address:
  • Phone: 415-645-4525
  • Fax: 510-399-1364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberSC006389
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberE6005
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: