Healthcare Provider Details

I. General information

NPI: 1710190087
Provider Name (Legal Business Name): JOHN MICHAEL BALLESTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

6572 FARMBROOK CT
MASON OH
45040-8962
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-3356
  • Fax:
Mailing address:
  • Phone: 513-459-1003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35079397
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: