Provider Demographics
NPI:1851377139
Name:BALAKRISHNAN, RADHAKRISHNAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RADHAKRISHNAN
Middle Name:
Last Name:BALAKRISHNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6622 N 91ST AVE
Mailing Address - Street 2:STE 220
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-2569
Mailing Address - Country:US
Mailing Address - Phone:602-759-6883
Mailing Address - Fax:602-224-3358
Practice Address - Street 1:18699 N 67TH AVE
Practice Address - Street 2:SUITE 280
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7140
Practice Address - Country:US
Practice Address - Phone:623-240-4277
Practice Address - Fax:623-566-0263
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ34114207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ955768Medicaid
AZ103628Medicare PIN
23421Medicare UPIN