Provider Demographics
NPI:1164748562
Name:BALASUBRAMANIAN, SHAILESH
Entity Type:Individual
Prefix:
First Name:SHAILESH
Middle Name:
Last Name:BALASUBRAMANIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8771
Mailing Address - Fax:310-301-8771
Practice Address - Street 1:1223 16TH ST STE 3400
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1279
Practice Address - Country:US
Practice Address - Phone:310-449-0939
Practice Address - Fax:424-259-7790
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-12
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274282207R00000X
CAA168744207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine