Healthcare Provider Details

I. General information

NPI: 1487720330
Provider Name (Legal Business Name): KRISHNAMURTHY BALASUBRAMANIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 E 156TH ST
BRONX NY
10451
US

IV. Provider business mailing address

72-39 LITTLE NECK PARKWAY
GLEN OAKS NY
11004
US

V. Phone/Fax

Practice location:
  • Phone: 718-292-2820
  • Fax: 718-402-7996
Mailing address:
  • Phone: 718-292-2820
  • Fax: 718-402-7996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number128139
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: