Provider Demographics
NPI:1659321412
Name:BALACHANDRAN, SUPPIAH (MD)
Entity Type:Individual
Prefix:DR
First Name:SUPPIAH
Middle Name:
Last Name:BALACHANDRAN
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 1:301 UNIVERSITY BLVD.
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-1022
Mailing Address - Country:US
Mailing Address - Phone:409-772-0817
Mailing Address - Fax:409-772-0885
Practice Address - Street 1:301 UNIVERSITY BLVD.
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-1022
Practice Address - Country:US
Practice Address - Phone:409-772-0817
Practice Address - Fax:409-772-0885
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE7809174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist