Healthcare Provider Details

I. General information

NPI: 1700980174
Provider Name (Legal Business Name): MICHAEL DAVID BALL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 NW 10TH AVE.
AVA MO
65608-1359
US

IV. Provider business mailing address

PO BOX 1359
AVA MO
65608-1359
US

V. Phone/Fax

Practice location:
  • Phone: 417-683-4831
  • Fax:
Mailing address:
  • Phone: 417-683-4831
  • Fax: 417-683-1602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR6B35
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: