Healthcare Provider Details

I. General information

NPI: 1396928172
Provider Name (Legal Business Name): DEEPA BALASUBRAMANIAM M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10313 GEORGIA AVE STE 207
SILVER SPRING MD
20902-5006
US

IV. Provider business mailing address

10313 GEORGIA AVE STE 207
SILVER SPRING MD
20902-5006
US

V. Phone/Fax

Practice location:
  • Phone: 301-681-7010
  • Fax: 301-593-8366
Mailing address:
  • Phone: 301-681-7010
  • Fax: 301-593-8366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberD72822
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberD72822
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: