Provider Demographics
NPI:1447232905
Name:BALABAN, LORI W (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:W
Last Name:BALABAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5354
Mailing Address - Country:US
Mailing Address - Phone:434-296-9161
Mailing Address - Fax:434-977-6068
Practice Address - Street 1:1011 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5354
Practice Address - Country:US
Practice Address - Phone:434-296-9161
Practice Address - Fax:434-977-6068
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2012-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049502208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006725813Medicaid
VA010712OtherCIGNA
VA333846OtherANTHEM
VA267039OtherMAMSI/ALLIANCE
VA52387OtherVETRI
VA12952600002OtherSOUTHERN HEALTH