Provider Demographics
NPI:1275551160
Name:BALLO, BELA R (MD)
Entity Type:Individual
Prefix:DR
First Name:BELA
Middle Name:R
Last Name:BALLO
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 1:1789 SHAWANO AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3243
Mailing Address - Country:US
Mailing Address - Phone:920-499-1428
Mailing Address - Fax:920-499-7080
Practice Address - Street 1:1789 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3243
Practice Address - Country:US
Practice Address - Phone:920-499-1428
Practice Address - Fax:920-499-7080
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-85492085R0202X
MI43011162792085R0204X
WI540552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400134453OtherPTAN
OH176902Medicaid
WIK400134453OtherPTAN
OHF26918Medicare UPIN