Provider Demographics
NPI:1679500508
Name:MALA MURTHY BALAKUMAR MD PC
Entity Type:Organization
Organization Name:MALA MURTHY BALAKUMAR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MALA
Authorized Official - Middle Name:MURTHY
Authorized Official - Last Name:BALAKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-801-2288
Mailing Address - Street 1:56 SHADETREE LN
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2503
Mailing Address - Country:US
Mailing Address - Phone:516-801-2288
Mailing Address - Fax:
Practice Address - Street 1:140 LOCKWOOD AVE
Practice Address - Street 2:SUITE 216
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-4915
Practice Address - Country:US
Practice Address - Phone:516-801-2288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193074208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherTAX IDENTIFICATION NUMBER