Provider Demographics
NPI:1396936498
Name:BALASUBRAMANIAM, DEVASENA (MD)
Entity type:Individual
Prefix:
First Name:DEVASENA
Middle Name:
Last Name:BALASUBRAMANIAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 FLETCHER AVE
Mailing Address - Street 2:UNIT 7
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-3700
Mailing Address - Country:US
Mailing Address - Phone:781-862-0943
Mailing Address - Fax:
Practice Address - Street 1:40 SECOND AVE
Practice Address - Street 2:MASS GENERAL WEST
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451
Practice Address - Country:US
Practice Address - Phone:781-487-4350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA233639207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine