Provider Demographics
NPI:1043357262
Name:BALLARD, CHARLES HUNT (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:HUNT
Last Name:BALLARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12742 LIMONITE AVE
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-9630
Mailing Address - Country:US
Mailing Address - Phone:951-739-2712
Mailing Address - Fax:
Practice Address - Street 1:12742 LIMONITE AVE
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880-9630
Practice Address - Country:US
Practice Address - Phone:951-739-2712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS735207Q00000X
CA20A10039207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31887ZOtherSITE ZZZ
HIH100199Medicare PIN