Healthcare Provider Details

I. General information

NPI: 1992847669
Provider Name (Legal Business Name): BANTWAL SURESH BALIGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 SKYWAY DR SUITE 808
OPELIKA AL
36801-7137
US

IV. Provider business mailing address

3320 SKYWAY DR SUITE 808
OPELIKA AL
36801-7137
US

V. Phone/Fax

Practice location:
  • Phone: 334-737-2737
  • Fax: 334-821-1043
Mailing address:
  • Phone: 334-737-2737
  • Fax: 334-821-1043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number056680
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: