Provider Demographics
NPI:1225034010
Name:BALACHANDRAN, SUBRAMANIAM (MD)
Entity Type:Individual
Prefix:
First Name:SUBRAMANIAM
Middle Name:
Last Name:BALACHANDRAN
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:PO BOX 797
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-0797
Mailing Address - Country:US
Mailing Address - Phone:254-694-5092
Mailing Address - Fax:254-694-7039
Practice Address - Street 1:1007 S WILLIAM ST
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-3245
Practice Address - Country:US
Practice Address - Phone:903-799-3326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-26
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0656208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142587001Medicaid
LA1675661Medicaid
TX1365207-01Medicaid
TX15AROtherBLUE CROSS/BLUE SHIELD
TX0015ARMedicare PIN
C13099Medicare UPIN