Healthcare Provider Details

I. General information

NPI: 1891781084
Provider Name (Legal Business Name): MANUEL W BALLAS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LURAY DR
WINTERSVILLE OH
43953-3973
US

IV. Provider business mailing address

3136 WEST ST
WEIRTON WV
26062-4637
US

V. Phone/Fax

Practice location:
  • Phone: 740-314-8258
  • Fax: 304-723-2195
Mailing address:
  • Phone: 304-797-7733
  • Fax: 304-797-7740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number1576
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number34.006103
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: