Provider Demographics
NPI:1114193430
Name:BALLNER, ELIZABETH SARAH (DO)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SARAH
Last Name:BALLNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:SARAH
Other - Last Name:KUNKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:503-216-2906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO164338207R00000X, 208M00000X
DEC7-004048207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500662274Medicaid
ORP01228015OtherRR MEDICARE - PHS
ORR172142Medicare PIN
OR500662274Medicaid
ORR172143Medicare PIN
ORP01228015OtherRR MEDICARE - PHS