=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104875640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BALAKRISHNAN SATHISHCHANDAR M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 05/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2457 E MAIN ST SUITE 1E
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06705-2685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-753-8477
-----------------------------------------------------
Fax | 203-757-2617
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 287 WALSH AVE
-----------------------------------------------------
City | NEWINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06111-3542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-436-2732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 023468
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------