Provider Demographics
NPI:1033100516
Name:ANNADURAI, BALA P (MD)
Entity Type:Individual
Prefix:
First Name:BALA
Middle Name:P
Last Name:ANNADURAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2147 MOWRY AVE
Mailing Address - Street 2:SUITE D4
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1724
Mailing Address - Country:US
Mailing Address - Phone:510-574-0800
Mailing Address - Fax:510-574-0850
Practice Address - Street 1:2147 MOWRY AVE
Practice Address - Street 2:SUITE D4
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1724
Practice Address - Country:US
Practice Address - Phone:510-574-0800
Practice Address - Fax:510-574-0850
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA056197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00145281OtherRAILROAD MEDICARE
CA00A561970Medicaid
P00145281OtherRAILROAD MEDICARE
CA00A561970Medicaid