Provider Demographics
NPI:1598077679
Name:BALGURI, SUMANTH (MD, FAAFP)
Entity Type:Individual
Prefix:
First Name:SUMANTH
Middle Name:
Last Name:BALGURI
Suffix:
Gender:M
Credentials:MD, FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4100
Mailing Address - Country:US
Mailing Address - Phone:479-314-6030
Mailing Address - Fax:479-314-2021
Practice Address - Street 1:7301 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4100
Practice Address - Country:US
Practice Address - Phone:479-314-6030
Practice Address - Fax:479-314-2021
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288945207Q00000X
OK27769207Q00000X
ARE-8115207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR198945001Medicaid
AR198945001Medicaid