Provider Demographics
NPI:1336181437
Name:BALENALLI, SURESH (MD)
Entity Type:Individual
Prefix:DR
First Name:SURESH
Middle Name:
Last Name:BALENALLI
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:PO BOX 13308
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-0039
Mailing Address - Country:US
Mailing Address - Phone:520-836-6636
Mailing Address - Fax:
Practice Address - Street 1:1968 N PEART RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-2495
Practice Address - Country:US
Practice Address - Phone:520-836-6636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28920207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ543365Medicaid
AZ543365Medicaid
AZZ100694Medicare ID - Type Unspecified