Healthcare Provider Details

I. General information

NPI: 1710981519
Provider Name (Legal Business Name): JEFFREY DAVID BALLER D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 08/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 KANELL BLVD
POPLAR BLUFF MO
63901-3001
US

IV. Provider business mailing address

2600 KANELL BLVD
POPLAR BLUFF MO
63901-3001
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-4546
  • Fax: 573-785-6959
Mailing address:
  • Phone: 573-785-4546
  • Fax: 573-785-6959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2009020599
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: