Provider Demographics
NPI:1922040997
Name:BALLARD, MARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:BALLARD
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 1:3003 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3031
Mailing Address - Country:US
Mailing Address - Phone:602-282-9701
Mailing Address - Fax:602-282-9666
Practice Address - Street 1:3003 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3031
Practice Address - Country:US
Practice Address - Phone:602-282-9701
Practice Address - Fax:602-282-9666
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ53539207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1088426Medicaid
WA217000732Medicare ID - Type Unspecified
WA1088426Medicaid