Provider Demographics
NPI:1659326783
Name:BALLINGER, LARRY CLAY (DPM)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:CLAY
Last Name:BALLINGER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE# 54433
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3811 VALLEY CENTRE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3318
Practice Address - Country:US
Practice Address - Phone:858-554-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4626213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E46260Medicaid
V09861Medicare UPIN
CA000E46260Medicaid