Provider Demographics
NPI:1043311822
Name:JODY BALLOCH MD INC
Entity type:Organization
Organization Name:JODY BALLOCH MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-482-1416
Mailing Address - Street 1:3801 LAS POSAS RD # 106A
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-1427
Mailing Address - Country:US
Mailing Address - Phone:805-482-1416
Mailing Address - Fax:805-389-3047
Practice Address - Street 1:3801 LAS POSAS RD # 106A
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-1427
Practice Address - Country:US
Practice Address - Phone:805-482-1416
Practice Address - Fax:805-389-3047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13368OtherUPIN GROUP#
CAZZZ482532OtherBLUE SHIELD
CAZZZ482532OtherBLUE SHIELD
CAG02215Medicare UPIN