Provider Demographics
NPI:1922174192
Name:BALLIN, DARRYL J (MD,INC)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:J
Last Name:BALLIN
Suffix:
Gender:M
Credentials:MD,INC
Other - Prefix:
Other - First Name:DARRYL
Other - Middle Name:J
Other - Last Name:BALLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, INC
Mailing Address - Street 1:5525 ETIWANDA AVE
Mailing Address - Street 2:SUITE 224
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3647
Mailing Address - Country:US
Mailing Address - Phone:818-708-4848
Mailing Address - Fax:818-436-4680
Practice Address - Street 1:5525 ETIWANDA AVE
Practice Address - Street 2:SUITE 224
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3647
Practice Address - Country:US
Practice Address - Phone:818-708-4848
Practice Address - Fax:818-436-4680
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A51935207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG05802Medicare UPIN
CAA51935Medicare ID - Type UnspecifiedDARRYL J. BALLIN, M.D.,