Provider Demographics
NPI:1609214519
Name:BALAKRISHNAN, GAUTAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:
Last Name:BALAKRISHNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5301 FARAON ST STE 210B
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3512
Mailing Address - Country:US
Mailing Address - Phone:816-271-1385
Mailing Address - Fax:816-271-1379
Practice Address - Street 1:5301 FARAON ST STE 210B
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506
Practice Address - Country:US
Practice Address - Phone:816-271-1385
Practice Address - Fax:816-271-1379
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IAR9809207R00000X
MO2016023333207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine