Provider Demographics
NPI:1508050071
Name:BALLARD, PHILLIP AULT JR (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:AULT
Last Name:BALLARD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1229 MADISON
Mailing Address - Street 2:SUITE #820
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3539
Mailing Address - Country:US
Mailing Address - Phone:206-498-8766
Mailing Address - Fax:206-720-1595
Practice Address - Street 1:1229 MADISON
Practice Address - Street 2:SUITE #820
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3539
Practice Address - Country:US
Practice Address - Phone:206-498-8766
Practice Address - Fax:206-720-1595
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD000116842084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1045202Medicaid
WA1045202Medicaid