Provider Demographics
NPI:1457459919
Name:BALA, RAJARAM (MD)
Entity Type:Individual
Prefix:
First Name:RAJARAM
Middle Name:
Last Name:BALA
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 1:343 W HOUSTON ST
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205-2268
Mailing Address - Country:US
Mailing Address - Phone:210-225-3006
Mailing Address - Fax:210-271-7755
Practice Address - Street 1:343 W HOUSTON STREET
Practice Address - Street 2:SUITE 1002
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-2268
Practice Address - Country:US
Practice Address - Phone:210-225-3006
Practice Address - Fax:210-271-7755
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE49682086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
8F23618Medicare PIN
TXPENDINGMedicaid