Provider Demographics
NPI:1760408173
Name:BALLON, SAMUEL CYRIL (MD)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:CYRIL
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 1:815 POLLARD RD
Mailing Address - Street 2:ATTN: CGOPS
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1438
Mailing Address - Country:US
Mailing Address - Phone:408-378-6545
Mailing Address - Fax:408-378-6550
Practice Address - Street 1:815 POLLARD RD
Practice Address - Street 2:ATTN: CGOPS
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1438
Practice Address - Country:US
Practice Address - Phone:408-378-6545
Practice Address - Fax:408-378-6550
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21751207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G217514OtherMEDICARE PIN
CAGR0101630Medicaid
CAGR0101630Medicaid
CAA41369Medicare UPIN