Healthcare Provider Details

I. General information

NPI: 1083607519
Provider Name (Legal Business Name): PRATAP BALUSU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 W HIGH ST STE 250
LIMA OH
45801-3959
US

IV. Provider business mailing address

PO BOX 636930
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 419-227-7399
  • Fax: 419-229-0123
Mailing address:
  • Phone: 513-981-5015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number72413
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2028291
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 2
Identifier000000024961
Identifier TypeOTHER
Identifier State
Identifier IssuerANTHEM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: