Healthcare Provider Details

I. General information

NPI: 1316967854
Provider Name (Legal Business Name): BALAGANESH GOPURALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11480 BROOKSHIRE AVE STE 309
DOWNEY CA
90241-5025
US

IV. Provider business mailing address

11480 BROOKSHIRE AVE STE 309
DOWNEY CA
90241-5025
US

V. Phone/Fax

Practice location:
  • Phone: 562-869-1201
  • Fax: 562-869-1281
Mailing address:
  • Phone: 562-869-1201
  • Fax: 562-869-1281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number00024965
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberC139871
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: