Provider Demographics
NPI:1265592141
Name:NOBLE L BALLARD.MEDICAL CLINIC, PLLC
Entity type:Organization
Organization Name:NOBLE L BALLARD.MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NOBLE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:V
Authorized Official - Credentials:M D
Authorized Official - Phone:580-480-1900
Mailing Address - Street 1:1015 EAST BROADWAY STREET
Mailing Address - Street 2:STUITE 101
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521
Mailing Address - Country:US
Mailing Address - Phone:580-480-1900
Mailing Address - Fax:580-477-1936
Practice Address - Street 1:1015 EAST BROADWAY STREET
Practice Address - Street 2:STUITE 101
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521
Practice Address - Country:US
Practice Address - Phone:580-480-1900
Practice Address - Fax:580-477-1936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty