Provider Demographics
NPI:1043387046
Name:BALLENTINE, RENEE HEATHER (DO)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:HEATHER
Last Name:BALLENTINE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 IRVINE BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1451 IRVINE BLVD
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3804
Practice Address - Country:US
Practice Address - Phone:714-838-8878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX85090Medicaid
CA00AX85090Medicaid
CACB224377Medicare PIN