Provider Demographics
NPI:1619066123
Name:BALLON, BRUCE J (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:J
Last Name:BALLON
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 1:903 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-1697
Mailing Address - Country:US
Mailing Address - Phone:360-435-8595
Mailing Address - Fax:360-435-5233
Practice Address - Street 1:903 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-1697
Practice Address - Country:US
Practice Address - Phone:360-435-8595
Practice Address - Fax:360-435-5233
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029300207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8137275Medicaid
AB32762Medicare ID - Type Unspecified
WA8137275Medicaid