Provider Demographics
NPI:1356375976
Name:VISWANATHAN, BALA (MD)
Entity type:Individual
Prefix:
First Name:BALA
Middle Name:
Last Name:VISWANATHAN
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 1:19260 STONE OAK PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3365
Mailing Address - Country:US
Mailing Address - Phone:210-545-5455
Mailing Address - Fax:210-545-0222
Practice Address - Street 1:19260 STONE OAK PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3365
Practice Address - Country:US
Practice Address - Phone:210-545-5455
Practice Address - Fax:210-545-0222
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8766208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089817301Medicaid
TX00HU76Medicare PIN
TX089817301Medicaid