Provider Demographics
NPI:1780618314
Name:BALASUBRAMANIAM, SUSHEELA K (MD)
Entity type:Individual
Prefix:DR
First Name:SUSHEELA
Middle Name:K
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 1:399 E HIGHLAND AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3852
Mailing Address - Country:US
Mailing Address - Phone:909-886-4555
Mailing Address - Fax:909-881-0668
Practice Address - Street 1:399 E HIGHLAND AVE STE 301
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3852
Practice Address - Country:US
Practice Address - Phone:909-886-4555
Practice Address - Fax:909-881-0668
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA044907207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A449070Medicaid
E92566Medicare UPIN
00A449070Medicare ID - Type Unspecified