Healthcare Provider Details

I. General information

NPI: 1396709994
Provider Name (Legal Business Name): BALASUBRAMANIAM GULASEKARAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17215 STUDEBAKER RD SUITE 300
CERRITOS CA
90703-2548
US

IV. Provider business mailing address

17215 STUDEBAKER RD SUITE 300
CERRITOS CA
90703-2548
US

V. Phone/Fax

Practice location:
  • Phone: 562-924-7307
  • Fax: 562-860-9398
Mailing address:
  • Phone: 562-924-7307
  • Fax: 562-860-9398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberA35405
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: