Provider Demographics
NPI:1720835606
Name:NATARAJAN, BALAGANESH
Entity Type:Individual
Prefix:DR
First Name:BALAGANESH
Middle Name:
Last Name:NATARAJAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 LARCHMONT WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-2050
Mailing Address - Country:US
Mailing Address - Phone:570-574-9195
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2501
Practice Address - Country:US
Practice Address - Phone:217-383-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.083361207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine