Provider Demographics
NPI:1083607519
Name:BALUSU, PRATAP (MD)
Entity Type:Individual
Prefix:
First Name:PRATAP
Middle Name:
Last Name:BALUSU
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:PO BOX 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-981-5015
Mailing Address - Fax:
Practice Address - Street 1:750 W HIGH ST
Practice Address - Street 2:STE 250
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-3959
Practice Address - Country:US
Practice Address - Phone:419-227-7399
Practice Address - Fax:419-229-0123
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH72413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2028291Medicaid
000000024961OtherANTHEM
OHBA0825321Medicare ID - Type Unspecified
G59723Medicare UPIN