Provider Demographics
NPI:1205837200
Name:BALLARD, JEFFREY LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LAWRENCE
Last Name:BALLARD
Suffix:
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:PO BOX 6898
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-6898
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:STE. 850
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4225
Practice Address - Country:US
Practice Address - Phone:714-560-4450
Practice Address - Fax:714-560-4455
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG618362086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G618360Medicaid
050069CD43675OtherTRAILBLAZER
00G618360OtherBLUE SHIELD OF CA
00G618360 M46OtherCALOPTIMA
P00139413OtherRAILROAD MEDICARE
P00139413OtherRAILROAD MEDICARE
CA00G618360Medicaid