Provider Demographics
NPI:1164722013
Name:BALLIE, AVINASH LUTCHMIDATH (MD)
Entity Type:Individual
Prefix:
First Name:AVINASH
Middle Name:LUTCHMIDATH
Last Name:BALLIE
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 1:136 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:NY
Mailing Address - Zip Code:13492-2553
Mailing Address - Country:US
Mailing Address - Phone:646-334-4436
Mailing Address - Fax:
Practice Address - Street 1:1676 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502
Practice Address - Country:US
Practice Address - Phone:315-724-3456
Practice Address - Fax:315-724-6734
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY260616207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400052615Medicare PIN