Provider Demographics
NPI:1821278698
Name:BALASUNDARAM, PRIYANKHA (MD)
Entity Type:Individual
Prefix:
First Name:PRIYANKHA
Middle Name:
Last Name:BALASUNDARAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 NW ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-6537
Mailing Address - Country:US
Mailing Address - Phone:580-248-2288
Mailing Address - Fax:
Practice Address - Street 1:1202 NW ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-6537
Practice Address - Country:US
Practice Address - Phone:580-248-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LABT4601692-8387208600000X
IL125055402208600000X
OK30838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery