Provider Demographics
NPI:1962487306
Name:BALLOU, LAURENCE HAVENS JR (MD)
Entity Type:Individual
Prefix:MR
First Name:LAURENCE
Middle Name:HAVENS
Last Name:BALLOU
Suffix:JR
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 1:1011 N FRASER ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-2848
Mailing Address - Country:US
Mailing Address - Phone:843-527-3428
Mailing Address - Fax:843-546-8216
Practice Address - Street 1:1011 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2848
Practice Address - Country:US
Practice Address - Phone:843-527-3428
Practice Address - Fax:843-546-8216
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10488207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC104880Medicaid
SC104880Medicaid
SCD056785248Medicare ID - Type Unspecified