Provider Demographics
NPI:1861448615
Name:JABALLAS, ELVIRA R (MD)
Entity Type:Individual
Prefix:
First Name:ELVIRA
Middle Name:R
Last Name:JABALLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ELIZABETH PL
Mailing Address - Street 2:NWG, SUITE 500
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45408-1445
Mailing Address - Country:US
Mailing Address - Phone:937-443-0354
Mailing Address - Fax:937-443-0478
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:NWG, SUITE 500
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45408-1445
Practice Address - Country:US
Practice Address - Phone:937-443-0354
Practice Address - Fax:937-443-0478
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.034426208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0187775Medicaid
F40119Medicare UPIN
JA4055361Medicare ID - Type Unspecified