Provider Demographics
NPI:1356350201
Name:BLAIR, BALLARD GLENN (DPM)
Entity type:Individual
Prefix:
First Name:BALLARD
Middle Name:GLENN
Last Name:BLAIR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:B.
Other - Middle Name:GLENN
Other - Last Name:BLAIR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:375 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484
Mailing Address - Country:US
Mailing Address - Phone:203-929-5559
Mailing Address - Fax:203-929-5277
Practice Address - Street 1:375 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484
Practice Address - Country:US
Practice Address - Phone:203-929-5559
Practice Address - Fax:203-929-5277
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00419213EP1101X, 213ER0200X, 213ES0103X
CTCT000419213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004070918Medicaid
CT480000654Medicare PIN
CT1356350201Medicare NSC
CTT23311Medicare UPIN