Healthcare Provider Details

I. General information

NPI: 1134324528
Provider Name (Legal Business Name): JAMES ROBERT BALLARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 10/29/2021
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 NE 27TH ST STE 100
BEND OR
97701-7760
US

IV. Provider business mailing address

1550 NE 27TH ST STE 100
BEND OR
97701-7760
US

V. Phone/Fax

Practice location:
  • Phone: 541-313-8111
  • Fax: 541-313-8111
Mailing address:
  • Phone: 541-313-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number289654-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD197064
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: