Healthcare Provider Details

I. General information

NPI: 1255684643
Provider Name (Legal Business Name): BALAMATHEW R PUDOTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 S BALLENGER HWY
FLINT MI
48532-3640
US

IV. Provider business mailing address

2160 E HILL RD APT #41
GRAND BLANC MI
48439-5183
US

V. Phone/Fax

Practice location:
  • Phone: 810-424-9270
  • Fax:
Mailing address:
  • Phone: 810-919-8567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302039319
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: