Provider Demographics
NPI:1336880657
Name:THEVAKUMAR, BALASINGAM (MD)
Entity Type:Individual
Prefix:
First Name:BALASINGAM
Middle Name:
Last Name:THEVAKUMAR
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 1:8245 N 27TH AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-6369
Mailing Address - Country:US
Mailing Address - Phone:916-934-8724
Mailing Address - Fax:
Practice Address - Street 1:4120 N 108TH AVE STE 116
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5773
Practice Address - Country:US
Practice Address - Phone:623-872-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-02
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR79125390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program