Provider Demographics
NPI:1891817029
Name:AKSHAYA BALAJI LLC
Entity Type:Organization
Organization Name:AKSHAYA BALAJI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGARAJAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-650-0018
Mailing Address - Street 1:6000 TARAWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-4422
Mailing Address - Country:US
Mailing Address - Phone:407-650-0018
Mailing Address - Fax:407-650-0118
Practice Address - Street 1:301 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:407-650-0018
Practice Address - Fax:407-650-0118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL72472174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254154800Medicaid
FL254154800Medicaid
FLF89146Medicare UPIN