Provider Demographics
NPI:1639300072
Name:BALLIET, MICHAEL RYAN (OD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RYAN
Last Name:BALLIET
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 1:538 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:PALMERTON
Mailing Address - State:PA
Mailing Address - Zip Code:18071-1911
Mailing Address - Country:US
Mailing Address - Phone:610-826-2222
Mailing Address - Fax:610-826-4001
Practice Address - Street 1:538 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:PALMERTON
Practice Address - State:PA
Practice Address - Zip Code:18071-1911
Practice Address - Country:US
Practice Address - Phone:610-826-2222
Practice Address - Fax:610-826-4001
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002270152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist