Provider Demographics
NPI:1437139680
Name:BALWAN, KHOUSIDAI S (MD)
Entity Type:Individual
Prefix:DR
First Name:KHOUSIDAI
Middle Name:S
Last Name:BALWAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:972 BRUSH HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1740
Mailing Address - Country:US
Mailing Address - Phone:516-876-5555
Mailing Address - Fax:516-876-1246
Practice Address - Street 1:865 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5310
Practice Address - Country:US
Practice Address - Phone:516-622-5000
Practice Address - Fax:516-622-5005
Is Sole Proprietor?:No
Enumeration Date:2006-01-21
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY211415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02182305Medicaid
NY02182305Medicaid
NYH38959Medicare UPIN