Provider Demographics
NPI:1700809076
Name:BALLAS, CHRISTOPHER T (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:T
Last Name:BALLAS
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 1:215 BACK NECK ROAD
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302
Mailing Address - Country:US
Mailing Address - Phone:856-451-4414
Mailing Address - Fax:856-451-2052
Practice Address - Street 1:215 BACK NECK RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-6834
Practice Address - Country:US
Practice Address - Phone:856-451-4414
Practice Address - Fax:856-451-2052
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06437400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7458908Medicaid
7363375SCWMedicare ID - Type Unspecified
G20361Medicare UPIN