Provider Demographics
NPI:1093744237
Name:BALLENGER, LUKE W III (MD)
Entity Type:Individual
Prefix:DR
First Name:LUKE
Middle Name:W
Last Name:BALLENGER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4140
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241
Mailing Address - Country:US
Mailing Address - Phone:207-777-4111
Mailing Address - Fax:207-783-6660
Practice Address - Street 1:100 CAMPUS AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6040
Practice Address - Country:US
Practice Address - Phone:207-777-8974
Practice Address - Fax:207-777-8946
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0140032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME328040099Medicaid
MEE86815Medicare UPIN
MEMM6012Medicare ID - Type Unspecified