Healthcare Provider Details

I. General information

NPI: 1912916529
Provider Name (Legal Business Name): GANAPATHY BALA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 S PUEBLO BLVD
PUEBLO CO
81005-2191
US

IV. Provider business mailing address

1315 S PUEBLO BLVD
PUEBLO CO
81005-2191
US

V. Phone/Fax

Practice location:
  • Phone: 719-561-9757
  • Fax: 719-561-9764
Mailing address:
  • Phone: 719-561-9757
  • Fax: 719-561-9764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number36577
License Number StateCO

VIII. Authorized Official

Name: GANAPATHY BALA
Title or Position: OWNER
Credential: M.D.
Phone: 719-561-9757