Healthcare Provider Details

I. General information

NPI: 1447869839
Provider Name (Legal Business Name): BRIAN BALLIOS MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 CHARLES ST RM 319
BOSTON MA
02114-3002
US

IV. Provider business mailing address

8 WHITTIER PL APT 21A
BOSTON MA
02114-1426
US

V. Phone/Fax

Practice location:
  • Phone: 617-573-3621
  • Fax:
Mailing address:
  • Phone: 617-510-8752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number283016
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: