Provider Demographics
NPI:1548230071
Name:BALLENTINE, KENNETH H (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:H
Last Name:BALLENTINE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5275 PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-5031
Mailing Address - Country:US
Mailing Address - Phone:408-255-0576
Mailing Address - Fax:408-255-0577
Practice Address - Street 1:5275 PROSPECT RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-5031
Practice Address - Country:US
Practice Address - Phone:408-255-0576
Practice Address - Fax:408-255-0577
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6863T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-2710370OtherFEDERAL TAXPAYER ID
CASD0068630Medicaid
CA0154770001Medicare NSC
SD0068630Medicare PIN
CA94-2710370OtherFEDERAL TAXPAYER ID