Provider Demographics
NPI:1912919648
Name:BALLARD, ROBERT EUGENE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EUGENE
Last Name:BALLARD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 PACIFIC AVE
Mailing Address - Street 2:205
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-1322
Mailing Address - Country:US
Mailing Address - Phone:562-437-6026
Mailing Address - Fax:
Practice Address - Street 1:37 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4804
Practice Address - Country:US
Practice Address - Phone:562-435-6219
Practice Address - Fax:562-432-6957
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5130T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist