Provider Demographics
NPI:1770564080
Name:BALASEKARAN, BHUVANA (MD)
Entity type:Individual
Prefix:
First Name:BHUVANA
Middle Name:
Last Name:BALASEKARAN
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 1:1301 W. WALL ST.
Mailing Address - Street 2:STE C
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701
Mailing Address - Country:US
Mailing Address - Phone:432-570-4500
Mailing Address - Fax:432-522-2115
Practice Address - Street 1:1301 W. WALL ST.
Practice Address - Street 2:STE C
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701
Practice Address - Country:US
Practice Address - Phone:432-570-4500
Practice Address - Fax:432-522-2115
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX470889174OtherFEDERAL TAX ID
TX153987601Medicaid
TX153987601Medicaid
TX00204HMedicare ID - Type Unspecified
TX470889174OtherFEDERAL TAX ID