Provider Demographics
NPI:1457969164
Name:PAVITRA BALASUBRAMANIAN, UNKNOWN (MD)
Entity Type:Individual
Prefix:
First Name:UNKNOWN
Middle Name:
Last Name:PAVITRA BALASUBRAMANIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PAVITRA
Other - Middle Name:
Other - Last Name:BALASUBRAMANIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1770 GRAND CONCOURSE APT 4L
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-5527
Mailing Address - Country:US
Mailing Address - Phone:914-415-8830
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-590-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101277334207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program