Healthcare Provider Details

I. General information

NPI: 1740235720
Provider Name (Legal Business Name): CAROLYN OATES BALLANTINE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 FULTON ST DURHAM VAMC, MAIL CODE 116-A
DURHAM NC
27705-3875
US

IV. Provider business mailing address

8804 WELLSLEY WAY
RALEIGH NC
27613-1358
US

V. Phone/Fax

Practice location:
  • Phone: 919-212-3011
  • Fax: 919-255-1540
Mailing address:
  • Phone: 919-593-5548
  • Fax: 919-929-8900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number200201134
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: