Provider Demographics
NPI:1174560080
Name:BALLIET, PAUL A (OD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:BALLIET
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 1:200 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5675
Mailing Address - Country:US
Mailing Address - Phone:701-222-3937
Mailing Address - Fax:701-222-8805
Practice Address - Street 1:200 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5675
Practice Address - Country:US
Practice Address - Phone:701-222-3937
Practice Address - Fax:701-222-8805
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND448152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1454550Medicaid
488241044246OtherPREFERRED ONE
SD9202520Medicaid
800448OtherNDVSI
61503OtherCOAST TO COAST
21748OtherSIOUX VALLEY HEALTH PLAN
410018232OtherRAILROAD MEDICARE ID
ND0448OtherEYEMED
ND200OtherVISION BENEFITS OF AMERIC
ND11169OtherBCBS
ND60355Medicaid
22-03326OtherMEDICA
22-03326OtherMEDICA
11169Medicare PIN