Provider Demographics
NPI:1649214644
Name:BALA, MANGALAM (MD)
Entity Type:Individual
Prefix:
First Name:MANGALAM
Middle Name:
Last Name:BALA
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 1:2300 BUFFALO RD
Mailing Address - Street 2:BLDG. 200
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-1360
Mailing Address - Country:US
Mailing Address - Phone:585-368-6370
Mailing Address - Fax:585-368-3671
Practice Address - Street 1:2300 BUFFALO RD
Practice Address - Street 2:BLDG. 200
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-1360
Practice Address - Country:US
Practice Address - Phone:585-368-6370
Practice Address - Fax:585-368-3671
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190510207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY102721BJOtherPREFERRED CARE
NY7559019OtherAETNA
NY01674015Medicaid
NY000911377002OtherHEALTHNOW
NY190510-8WOtherWORKER'S COMPENSATION
NY190510-8WOtherWORKER'S COMPENSATION
NY01674015Medicaid