Provider Demographics
NPI:1972509438
Name:BALA, GANAPATHY (MD)
Entity Type:Individual
Prefix:MR
First Name:GANAPATHY
Middle Name:
Last Name:BALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 S PUEBLO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2191
Mailing Address - Country:US
Mailing Address - Phone:719-561-9757
Mailing Address - Fax:719-561-9764
Practice Address - Street 1:1315 S PUEBLO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2191
Practice Address - Country:US
Practice Address - Phone:719-561-9757
Practice Address - Fax:719-561-9764
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36577207K00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01365774Medicaid
F82522Medicare UPIN
COC 801686Medicare PIN