Provider Demographics
NPI:1407985278
Name:BALL, GREGORY R (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:R
Last Name:BALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:775 POLE LINE RD W
Practice Address - Street 2:SUITE 315
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5814
Practice Address - Country:US
Practice Address - Phone:208-814-8750
Practice Address - Fax:208-814-8937
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO0575207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1407985278Medicaid
IDP0034096OtherMCRR
ID1407985278Medicaid
ID11962551Medicare PIN