Basic Information
| Provider Information | |||||||||
| NPI: | 1801935697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLONOFF | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 ELDORADO BLVD STE 6250 | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800213421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032720768 | ||||||||
| FaxNumber: | 3033182488 | ||||||||
| Practice Location | |||||||||
| Address1: | 1960 OGDEN ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802183670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033181540 | ||||||||
| FaxNumber: | 3033182481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 18301 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01183011 | 05 | CO | MEDICAID |