Provider Demographics
NPI:1639125727
Name:BALLARD, NOBLE LEE (M D)
Entity Type:Individual
Prefix:DR
First Name:NOBLE
Middle Name:LEE
Last Name:BALLARD
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E PECAN ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-6141
Mailing Address - Country:US
Mailing Address - Phone:580-379-5000
Mailing Address - Fax:580-379-5509
Practice Address - Street 1:205 S PARK LN
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5755
Practice Address - Country:US
Practice Address - Phone:580-379-6650
Practice Address - Fax:580-379-6659
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100116210AMedicaid
OK100116210AMedicaid
C94662Medicare UPIN