Provider Demographics
NPI:1093777435
Name:BALAKRISHNAN, SUSHILA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSHILA
Middle Name:
Last Name:BALAKRISHNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSHILA
Other - Middle Name:
Other - Last Name:ARASARETNAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:197 CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3328
Mailing Address - Country:US
Mailing Address - Phone:718-447-5442
Mailing Address - Fax:
Practice Address - Street 1:111 CANAL ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2723
Practice Address - Country:US
Practice Address - Phone:718-390-0712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117311174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNY117311OtherLICENSE