Provider Demographics
NPI:1104972140
Name:BALL, BLAIR M (OD)
Entity type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:M
Last Name:BALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1659 E 6TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-2509
Mailing Address - Country:US
Mailing Address - Phone:951-845-0272
Mailing Address - Fax:951-845-0143
Practice Address - Street 1:1659 E 6TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-2509
Practice Address - Country:US
Practice Address - Phone:951-845-0272
Practice Address - Fax:951-845-0143
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2010-06-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CASD0084220 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0084220Medicaid
CASD0084220Medicare PIN
CA0421440001Medicare NSC
CASD0084220Medicaid
CA410019482Medicare PIN