Provider Demographics
NPI:1124154943
Name:BALLENTINE, RALPH E (MD)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:E
Last Name:BALLENTINE
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 1:1840 LAKE EMMA RD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-7137
Mailing Address - Country:US
Mailing Address - Phone:321-695-0157
Mailing Address - Fax:407-682-4405
Practice Address - Street 1:237 FERNWOOD BLVD
Practice Address - Street 2:
Practice Address - City:FERN PARK
Practice Address - State:FL
Practice Address - Zip Code:32730-2116
Practice Address - Country:US
Practice Address - Phone:407-831-2411
Practice Address - Fax:407-831-0195
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME177422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280555300Medicaid
FL280555300Medicaid