Healthcare Provider Details

I. General information

NPI: 1386134419
Provider Name (Legal Business Name): DAVID ADRIAN BALLACK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HEALTH PARK BLVD
ST AUGUSTINE FL
32086-5784
US

IV. Provider business mailing address

PO BOX 100183
GAINESVILLE FL
32610-0183
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-5155
  • Fax:
Mailing address:
  • Phone: 352-392-0104
  • Fax: 352-392-8217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number17707
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: