Healthcare Provider Details

I. General information

NPI: 1285649624
Provider Name (Legal Business Name): JAY BALLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 PHILADELPHIA DR
DAYTON OH
45406-1813
US

IV. Provider business mailing address

1563 E DOROTHY LN SUITE 101
KETTERING OH
45429-3897
US

V. Phone/Fax

Practice location:
  • Phone: 937-276-7623
  • Fax:
Mailing address:
  • Phone: 937-296-0253
  • Fax: 937-293-3183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35079834
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: