Basic Information
| Provider Information | |||||||||
| NPI: | 1336111541 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLARD | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 E. ELIZABETH STREET | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702679510 | ||||||||
| FaxNumber: | 9702079967 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 E. ELIZABETH ST. | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702679510 | ||||||||
| FaxNumber: | 9702079967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 38219 | CO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 25307266 | 05 | CO | MEDICAID |