Individual
DR. JORDAN BRETT BALLANTYNE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2799
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12141883
CAQH
CO
05
—
93920288
—
CO
01
—
COA105677
MEDICARE INDIVIDUAL PTAN
CO
Enumeration date
08/03/2010
Last updated
10/10/2016
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