Provider Demographics
NPI:1417065061
Name:BALAKRISHNAN, BEENA S (MD)
Entity Type:Individual
Prefix:DR
First Name:BEENA
Middle Name:S
Last Name:BALAKRISHNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BEENA
Other - Middle Name:
Other - Last Name:PONDUCHERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 422
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07642-0422
Mailing Address - Country:US
Mailing Address - Phone:201-690-6122
Mailing Address - Fax:
Practice Address - Street 1:223 N VAN DIEN AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2726
Practice Address - Country:US
Practice Address - Phone:201-690-6122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07973200208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0095265Medicaid
NJ142100Medicare PIN
NJI48594Medicare UPIN
NJ0095265Medicaid