Provider Demographics
NPI:1942322326
Name:BALLARD, DIANA MARIE (MD)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:MARIE
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 1:1115 WHISKEYTOWN CT # B
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0227
Mailing Address - Country:US
Mailing Address - Phone:530-244-9750
Mailing Address - Fax:
Practice Address - Street 1:1115 WHISKEYTOWN CT # B
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0227
Practice Address - Country:US
Practice Address - Phone:530-244-9750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG14717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA39317Medicare UPIN
CAG14717Medicare ID - Type UnspecifiedMEDICARE PROVIDER #