Provider Demographics
NPI:1386808202
Name:BALLOCH, RACHEL ELISE (DPM, AACFAS)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ELISE
Last Name:BALLOCH
Suffix:
Gender:F
Credentials:DPM, AACFAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SIMSBURY STE 209
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3793
Mailing Address - Country:US
Mailing Address - Phone:860-674-0284
Mailing Address - Fax:860-674-0292
Practice Address - Street 1:100 SIMSBURY RD STE 209
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3793
Practice Address - Country:US
Practice Address - Phone:860-674-0284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00297200213ES0103X
CT000850213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MD00297200OtherLICENSE