Provider Demographics
NPI:1558468181
Name:BALLARD, CAROL J (OD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:J
Last Name:BALLARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 1/2 E PUBLIC SQ
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37033-1601
Mailing Address - Country:US
Mailing Address - Phone:931-729-2190
Mailing Address - Fax:931-729-2805
Practice Address - Street 1:205 1/2 E PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37033-1601
Practice Address - Country:US
Practice Address - Phone:931-729-2190
Practice Address - Fax:931-729-2805
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000000807152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3595185Medicaid
TN103I411559OtherMEDICARE PART B
TN103I411559OtherMEDICARE PART B