Healthcare Provider Details

I. General information

NPI: 1033154380
Provider Name (Legal Business Name): DORAIKANNU BALAKUMAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 SAINT RAYMONDS AVE ANESTHESIA DEPARTMENT
BRONX NY
10461
US

IV. Provider business mailing address

PO BOX A ASSURE ANESTHESIA
NORTH BELLMORE NY
11710-0745
US

V. Phone/Fax

Practice location:
  • Phone: 718-430-7473
  • Fax: 718-430-7336
Mailing address:
  • Phone: 800-720-1664
  • Fax: 207-753-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA03728600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number140588
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: