Provider Demographics
NPI:1689871188
Name:BALLECER, CONRAD DIZON III (MD)
Entity Type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:DIZON
Last Name:BALLECER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3030 N CENTRAL AVE STE 1001
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2716
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:602-406-3874
Practice Address - Street 1:500 W THOMAS RD STE 400
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013
Practice Address - Country:US
Practice Address - Phone:602-406-3874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ81594208600000X
AZ37738208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery