Provider Demographics
NPI:1508283995
Name:BALLE, LARRY II
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:BALLE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W 34TH ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018-6206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 N PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6398
Practice Address - Country:US
Practice Address - Phone:479-966-4187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10031139281P00000X
ARE-10752207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No281P00000XHospitalsChronic Disease Hospital