Provider Demographics
NPI:1558749283
Name:BALASUBRAMANIAM, ASHWIN
Entity Type:Individual
Prefix:
First Name:ASHWIN
Middle Name:
Last Name:BALASUBRAMANIAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 MERRILEE DR
Mailing Address - Street 2:STE 230
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4400
Mailing Address - Country:US
Mailing Address - Phone:703-698-4488
Mailing Address - Fax:
Practice Address - Street 1:2722 MERRILEE DR STE 230
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4400
Practice Address - Country:US
Practice Address - Phone:703-698-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1677702085R0202X
MDD00922892085R0202X
VA01012725332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology