Provider Demographics
NPI:1780654392
Name:BALLES, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:BALLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:195 FORE RIVER PKWY STE 480
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2787
Mailing Address - Country:US
Mailing Address - Phone:207-773-3937
Mailing Address - Fax:207-773-0801
Practice Address - Street 1:195 FORE RIVER PKWY STE 480
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2787
Practice Address - Country:US
Practice Address - Phone:207-773-3937
Practice Address - Fax:207-773-0801
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME014047207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME130920000Medicaid
MER0007OtherBCBS GROUP NUMBER
ME298300099Medicaid
ME033680OtherBCBS STAR NUMBER
ME298300099Medicaid
ME298300099Medicaid
MEMM5852Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER