Provider Demographics
NPI:1194795518
Name:BALL, LEE W (MD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:W
Last Name:BALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LEE
Other - Middle Name:
Other - Last Name:SHUKLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9400 SW BARNES RD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6608
Mailing Address - Country:US
Mailing Address - Phone:503-292-9108
Mailing Address - Fax:503-292-0346
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:503-216-4830
Practice Address - Fax:503-216-4850
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15521174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR047451Medicaid
E97536Medicare UPIN
OR047451Medicaid