Healthcare Provider Details

I. General information

NPI: 1750397576
Provider Name (Legal Business Name): BALAMURALI KRISHNA AMBATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 S GARDEN WAY STE 250
EUGENE OR
97401-8175
US

IV. Provider business mailing address

360 S GARDEN WAY STE 250
EUGENE OR
97401-8175
US

V. Phone/Fax

Practice location:
  • Phone: 541-343-5000
  • Fax:
Mailing address:
  • Phone: 541-343-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number6771485-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD178830
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: