Provider Demographics
NPI:1770008914
Name:BALLANTYNE, MARIO DEON
Entity type:Individual
Prefix:MR
First Name:MARIO
Middle Name:DEON
Last Name:BALLANTYNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3945 ROSE OF SHARON DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-2738
Mailing Address - Country:US
Mailing Address - Phone:321-279-1218
Mailing Address - Fax:407-704-4464
Practice Address - Street 1:3945 ROSE OF SHARON DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-2738
Practice Address - Country:US
Practice Address - Phone:321-279-1218
Practice Address - Fax:407-704-4464
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLB453544754290172A00000X, 347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes347E00000XTransportation ServicesTransportation BrokerGroup - Single Specialty
No172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL81-0683776OtherIRS