Healthcare Provider Details

I. General information

NPI: 1821278698
Provider Name (Legal Business Name): PRIYANKHA BALASUNDARAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 W 19TH AVE
STILLWATER OK
74074-2732
US

IV. Provider business mailing address

3410 W 19TH AVE
STILLWATER OK
74074-2732
US

V. Phone/Fax

Practice location:
  • Phone: 405-252-1850
  • Fax: 405-999-4775
Mailing address:
  • Phone: 405-252-1850
  • Fax: 405-999-4775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30838
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberBT4601692-8387
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125055402
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: