Provider Demographics
NPI:1184799066
Name:BALASUBRAMANIAN, AMBALAVANAN (MD)
Entity type:Individual
Prefix:DR
First Name:AMBALAVANAN
Middle Name:
Last Name:BALASUBRAMANIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5311 OLD COURT RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5241
Mailing Address - Country:US
Mailing Address - Phone:410-922-7382
Mailing Address - Fax:410-922-7384
Practice Address - Street 1:5311 OLD COURT RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5241
Practice Address - Country:US
Practice Address - Phone:410-922-7382
Practice Address - Fax:410-922-7384
Is Sole Proprietor?:No
Enumeration Date:2006-11-23
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD65046207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine