Provider Demographics
NPI:1134184708
Name:BALASUBRAMANIAM, KUMARAVELU (MD)
Entity type:Individual
Prefix:DR
First Name:KUMARAVELU
Middle Name:
Last Name:BALASUBRAMANIAM
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 1:2006 N RIVERSIDE AVE
Mailing Address - Street 2:STE B
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-4696
Mailing Address - Country:US
Mailing Address - Phone:909-881-3032
Mailing Address - Fax:909-881-0668
Practice Address - Street 1:2006 N RIVERSIDE AVE
Practice Address - Street 2:STE B
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92377-4696
Practice Address - Country:US
Practice Address - Phone:909-881-3032
Practice Address - Fax:909-881-0668
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44716207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A447160Medicare UPIN
CAF03161Medicare UPIN