Provider Demographics
NPI:1053330779
Name:BALLANCO, GERARD A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:A
Last Name:BALLANCO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 KILBOURNE CIR
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-5374
Mailing Address - Country:US
Mailing Address - Phone:337-886-6848
Mailing Address - Fax:
Practice Address - Street 1:539 E PRUDHOMME ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6499
Practice Address - Country:US
Practice Address - Phone:337-942-6883
Practice Address - Fax:337-942-6830
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0256452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1043184Medicaid
LAP00390429OtherRAILROAD RETIREMENT MEDIC
LA4J213Medicare PIN
LA1043184Medicaid