Healthcare Provider Details

I. General information

NPI: 1225100449
Provider Name (Legal Business Name): ELITA G. BALAKRISHNAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST
BRONX NY
10451-5504
US

IV. Provider business mailing address

214 FORT LEE PL
ORANGEBURG NY
10962-2707
US

V. Phone/Fax

Practice location:
  • Phone: 718-579-5000
  • Fax: 718-579-4700
Mailing address:
  • Phone: 718-579-5000
  • Fax: 718-579-4700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number114964
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: