Provider Demographics
NPI:1588613111
Name:BALAKRISHNAN, ROJA (MD)
Entity Type:Individual
Prefix:
First Name:ROJA
Middle Name:
Last Name:BALAKRISHNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MO
Mailing Address - Zip Code:65559-1926
Mailing Address - Country:US
Mailing Address - Phone:573-265-0448
Mailing Address - Fax:
Practice Address - Street 1:620 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:MO
Practice Address - Zip Code:65559-1926
Practice Address - Country:US
Practice Address - Phone:573-265-0448
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD104074207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF41399Medicare UPIN