Provider Demographics
NPI:1386662351
Name:BALA, VANITHA (MD)
Entity Type:Individual
Prefix:DR
First Name:VANITHA
Middle Name:
Last Name:BALA
Suffix:
Gender:F
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 130894
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77393
Mailing Address - Country:US
Mailing Address - Phone:936-321-0033
Mailing Address - Fax:
Practice Address - Street 1:111 VISION PARK BLVD
Practice Address - Street 2:STE 150
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3002
Practice Address - Country:US
Practice Address - Phone:936-321-0033
Practice Address - Fax:936-321-0032
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055919207R00000X
VA0116022282390200000X
TXQ0405207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345954701Medicaid
TX374939YZZHMedicare UPIN