Provider Demographics
NPI:1184660821
Name:BALLOW, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BALLOW
Suffix:
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-2812
Practice Address - Street 1:2 TAMPA GENERAL CIR
Practice Address - Street 2:STC 5TH FLOOR
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3603
Practice Address - Country:US
Practice Address - Phone:727-767-4150
Practice Address - Fax:727-767-8532
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174470-1207K00000X
NY1744702080P0201X
FLME1120112080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008130000Medicaid
040426000993OtherFIDELIS
FL14P6JOtherBLUE CROSS BLUE SHIELD
00010009301OtherUNIVERA
000510824001OtherBC/BS
PA0011295550001Medicaid
0207420OtherIHA
NY01084606Medicaid
0207420OtherIHA
FL14P6JOtherBLUE CROSS BLUE SHIELD
NYC64942Medicare UPIN