Provider Demographics
NPI:1447562640
Name:BALRAJ, PRAVEEN CHANDAR (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAVEEN CHANDAR
Middle Name:
Last Name:BALRAJ
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 1:2040 S ALMA SCHOOL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-7076
Mailing Address - Country:US
Mailing Address - Phone:480-936-7722
Mailing Address - Fax:480-936-7723
Practice Address - Street 1:21321 E OCOTILLO RD STE 125
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-5995
Practice Address - Country:US
Practice Address - Phone:480-936-7722
Practice Address - Fax:480-936-7723
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT191085208600000X
MI43011035192086S0129X
AZ550782086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ316871Medicaid