Provider Demographics
NPI:1265694731
Name:SAMBANDAM, BALAGURU KOLANDAVELO (MD)
Entity type:Individual
Prefix:
First Name:BALAGURU
Middle Name:KOLANDAVELO
Last Name:SAMBANDAM
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 1:1540 KELLER PKWY # 108-249
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3686
Mailing Address - Country:US
Mailing Address - Phone:817-717-5268
Mailing Address - Fax:817-717-8021
Practice Address - Street 1:3025 N TARRANT PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-8625
Practice Address - Country:US
Practice Address - Phone:817-717-5268
Practice Address - Fax:817-717-8021
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5128208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery