Provider Demographics
NPI:1326362278
Name:BALLANTINE, CHARLOTTE (DO)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:BALLANTINE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MSC10 5550 1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-4661
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-9654
Practice Address - Country:US
Practice Address - Phone:720-692-6068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
NM390200000X
NMDO2023-1011207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program