MEDICARE: ALLUSTRA DERMATOLOGY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	363A00000X	Physician Assistant
2	363L00000X	Nurse Practitioner
3	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1881337715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLUSTRA DERMATOLOGY, PLLC

Provider Business Mailing Address
First Line	:	2429 BISSONNET ST # 552
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-1451
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1740 W 27TH ST STE 315
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-1437
Country	:	US
Telephone Number	:	713-868-5861
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. BRUNDHA BALARAMAN
Credential	:	MD
Telephone Number	:	713-868-5861

Provider Enumeration Date	:	04/19/2022
Last Update Date	:	11/19/2022

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