Provider Demographics
NPI:1326352212
Name:BALLANTYNE, JORDAN BRETT (OD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:BRETT
Last Name:BALLANTYNE
Suffix:
Gender:M
Credentials:OD
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 305
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-0305
Mailing Address - Country:US
Mailing Address - Phone:719-383-0134
Mailing Address - Fax:719-404-1825
Practice Address - Street 1:302 W 3RD ST
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-1430
Practice Address - Country:US
Practice Address - Phone:719-383-0134
Practice Address - Fax:719-404-1825
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2799152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO93920288Medicaid
COCOA105677OtherMEDICARE INDIVIDUAL PTAN
CO12141883OtherCAQH