Healthcare Provider Details

I. General information

NPI: 1144269937
Provider Name (Legal Business Name): DHEEPA BALAKRISHNAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/20/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST 3110 BERRY PAVILION
DAYTON OH
45409-2722
US

IV. Provider business mailing address

1 WYOMING ST 3110 BERRY PAVILION
DAYTON OH
45409-2722
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-6800
  • Fax: 937-208-2139
Mailing address:
  • Phone: 937-208-6800
  • Fax: 937-208-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35.086629
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: