Provider Demographics
NPI:1689201535
Name:BALLICH, DANIA (MD)
Entity type:Individual
Prefix:
First Name:DANIA
Middle Name:
Last Name:BALLICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8900
Mailing Address - Country:US
Mailing Address - Phone:727-322-1054
Mailing Address - Fax:727-821-7213
Practice Address - Street 1:1839 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8900
Practice Address - Country:US
Practice Address - Phone:727-322-1054
Practice Address - Fax:727-821-7213
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME163452207RH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122518200Medicaid