Provider Demographics
NPI:1760483457
Name:BALLARD, LYDIA RENE (MD)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:RENE
Last Name:BALLARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:950 N PORTER AVE
Mailing Address - Street 2:SUITE #300
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6400
Mailing Address - Country:US
Mailing Address - Phone:405-329-0121
Mailing Address - Fax:405-292-6099
Practice Address - Street 1:950 N PORTER AVE
Practice Address - Street 2:SUITE #300
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6400
Practice Address - Country:US
Practice Address - Phone:405-329-0121
Practice Address - Fax:405-292-6099
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK18425207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100138140BMedicaid
OK110218258OtherRAILROAD MEDICARE
OK5222147OtherAETNA EDI #
OK100138140BMedicaid