Healthcare Provider Details

I. General information

NPI: 1548292303
Provider Name (Legal Business Name): AMARAVATHI BALAKRISHNAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N JACKSON AVE STE 101 SUITE 101
SAN JOSE CA
95116-1925
US

IV. Provider business mailing address

155 N JACKSON AVE STE 101
SAN JOSE CA
95116-1925
US

V. Phone/Fax

Practice location:
  • Phone: 408-259-1250
  • Fax: 408-259-7439
Mailing address:
  • Phone: 408-259-1250
  • Fax: 408-259-7439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA30274
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: