Provider Demographics
NPI:1467652560
Name:BALLARD, DARREN (MD)
Entity Type:Individual
Prefix:DR
First Name:DARREN
Middle Name:
Last Name:BALLARD
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 1:17901 GOVERNORS HWY STE 106
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-1145
Mailing Address - Country:US
Mailing Address - Phone:708-799-3305
Mailing Address - Fax:
Practice Address - Street 1:17901 GOVERNORS HWY STE 106
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1145
Practice Address - Country:US
Practice Address - Phone:708-799-3305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360144348207RG0100X
WI62299207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1467652560Medicaid
WIK400139281Medicare PIN