Provider Demographics
NPI:1194192872
Name:BALU, BHARATH (MD, PA-C)
Entity Type:Individual
Prefix:MR
First Name:BHARATH
Middle Name:
Last Name:BALU
Suffix:
Gender:M
Credentials:MD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6934 AVIATION BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-2593
Mailing Address - Country:US
Mailing Address - Phone:443-949-0814
Mailing Address - Fax:443-949-0825
Practice Address - Street 1:16 WOODBINE LANE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-2143
Practice Address - Country:US
Practice Address - Phone:570-271-8050
Practice Address - Fax:570-271-5940
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMT220424207R00000X, 207N00000X
MDC0005826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant