Provider Demographics
NPI:1083789556
Name:BALASHOV, KONSTANTIN (MD, PHD)
Entity Type:Individual
Prefix:
First Name:KONSTANTIN
Middle Name:
Last Name:BALASHOV
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVENUE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY STREET, SUITE 7B
Practice Address - Street 2:SHAPIRO BLDG
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-8456
Practice Address - Fax:617-638-8465
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2203202084N0400X
NJ25MA078878002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3125305Medicaid
NJ0065951Medicaid
MA110164678AMedicaid