Provider Demographics
NPI:1922547629
Name:BALI, SOFINA
Entity Type:Individual
Prefix:
First Name:SOFINA
Middle Name:
Last Name:BALI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4627 CEDAR WOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-4289
Mailing Address - Country:US
Mailing Address - Phone:404-368-9305
Mailing Address - Fax:
Practice Address - Street 1:4627 CEDAR WOOD DR SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-4289
Practice Address - Country:US
Practice Address - Phone:404-368-9305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306581207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program