Healthcare Provider Details

I. General information

NPI: 1396804621
Provider Name (Legal Business Name): DAVID WAYNE BALLARD IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 12/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL UNDERSEA MEDICAL INSTITUTE SUBMARINE BASE
GROTON CT
06349-5159
US

IV. Provider business mailing address

8 SHERWOOD TRACE
GALES FERRY CT
06335
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-2876
  • Fax:
Mailing address:
  • Phone: 860-514-0873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: