Provider Demographics
NPI:1508974056
Name:BALKISSOON, JAIKRISHNA (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIKRISHNA
Middle Name:
Last Name:BALKISSOON
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 1:2999 REGENT ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2146
Mailing Address - Country:US
Mailing Address - Phone:510-548-1717
Mailing Address - Fax:510-548-1715
Practice Address - Street 1:2999 REGENT ST
Practice Address - Street 2:SUITE 300
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2146
Practice Address - Country:US
Practice Address - Phone:510-548-1717
Practice Address - Fax:510-548-1715
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0713632086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF36983Medicare UPIN
CAG713630Medicare ID - Type Unspecified