Healthcare Provider Details

I. General information

NPI: 1477647097
Provider Name (Legal Business Name): KANDASAMY AMBALAVANAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6225 SMITH AVE
BALTIMORE MD
21209-3626
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
BALTIMORE MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0051596
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: