Provider Demographics
NPI:1376522573
Name:BALLIF, MARK G (MD,)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:BALLIF
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 1:4360 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-6529
Mailing Address - Country:US
Mailing Address - Phone:801-476-0494
Mailing Address - Fax:801-476-0067
Practice Address - Street 1:4360 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1866
Practice Address - Country:US
Practice Address - Phone:801-476-0494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT176195-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTC63346Medicare UPIN