Provider Demographics
NPI:1366739054
Name:BALLARD, RICHARD DANE (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DANE
Last Name:BALLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 GLOSTER CREEK VLG STE A2
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4749
Mailing Address - Country:US
Mailing Address - Phone:662-620-6800
Mailing Address - Fax:662-620-6950
Practice Address - Street 1:499 GLOSTER CREEK VLG STE A2
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801
Practice Address - Country:US
Practice Address - Phone:662-620-6800
Practice Address - Fax:662-620-6950
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22430207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MST-2401OtherTEMPORARY MS MEDICAL LICENSE
MS05300066Medicaid