Provider Demographics
NPI:1821075730
Name:BALLARD, TIMOTHY D (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:D
Last Name:BALLARD
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 1:4881 SUGAR MAPLE DR
Mailing Address - Street 2:BLDG 830
Mailing Address - City:WRIGHT PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5529
Mailing Address - Country:US
Mailing Address - Phone:937-257-1942
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:BLDG 830
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-1942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.088367207Q00000X
OH35-883672083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2764398Medicaid
OH000000510374OtherANTHEM/BCBS
OH000000551694OtherANTHEM/BCBS
OH000000510374OtherANTHEM/BCBS
OH000000551694OtherANTHEM/BCBS