Provider Demographics
NPI:1356552095
Name:DATTI, BALAJI S (MD)
Entity type:Individual
Prefix:
First Name:BALAJI
Middle Name:S
Last Name:DATTI
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 1:2200 SW 6TH AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1707
Mailing Address - Country:US
Mailing Address - Phone:785-354-8518
Mailing Address - Fax:785-354-1255
Practice Address - Street 1:2200 SW 6TH AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1707
Practice Address - Country:US
Practice Address - Phone:785-354-8518
Practice Address - Fax:785-354-1255
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-36685207RG0100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201085050AMedicaid
KS110426028Medicare PIN