Healthcare Provider Details

I. General information

NPI: 1184660821
Provider Name (Legal Business Name): MARK BALLOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 TAMPA GENERAL CIR STC 5TH FLOOR
TAMPA FL
33606-3603
US

IV. Provider business mailing address

PO BOX 917770
ORLANDO FL
32891-0001
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-4150
  • Fax: 727-767-8532
Mailing address:
  • Phone: 813-974-2201
  • Fax: 813-974-2812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number174470-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number174470
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberME112011
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: