Healthcare Provider Details

I. General information

NPI: 1497857254
Provider Name (Legal Business Name): BALASUBRAMANI NATARAJAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BALA NATARAJAN M.D.

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD DEPT OF
PHILADELPHIA PA
19141-3018
US

IV. Provider business mailing address

231 TRIANON LN
VILLANOVA PA
19085-1444
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-6433
  • Fax:
Mailing address:
  • Phone: 405-905-9080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD452186
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25937
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD452186
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: