Healthcare Provider Details

I. General information

NPI: 1164679668
Provider Name (Legal Business Name): CHRISTOPHER J BALLARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 SEMINOLE BLVD STE 205
LARGO FL
33778-3240
US

IV. Provider business mailing address

4651 VAN DYKE RD
LUTZ FL
33558-4880
US

V. Phone/Fax

Practice location:
  • Phone: 813-321-1786
  • Fax: 813-321-1787
Mailing address:
  • Phone: 813-321-1786
  • Fax: 813-321-1786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME109317
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: