Provider Demographics
NPI:1063776466
Name:BALLIET, MEGAN S (DPM)
Entity type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:S
Last Name:BALLIET
Suffix:
Gender:
Credentials:DPM
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:E
Other - Last Name:STATKEWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:20130 LAKE CHABOT RD STE 202
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5340
Mailing Address - Country:US
Mailing Address - Phone:415-645-4525
Mailing Address - Fax:510-399-1364
Practice Address - Street 1:400 PARNASSUS AVE # A-501
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2202
Practice Address - Country:US
Practice Address - Phone:415-353-2357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006389213ES0131X
CAE6005213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery