Provider Demographics
NPI:1881389542
Name:BALAGURU, ASHWIN ARAVINTHAN
Entity type:Individual
Prefix:
First Name:ASHWIN
Middle Name:ARAVINTHAN
Last Name:BALAGURU
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 1:4040 SHORELAKE CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2036
Mailing Address - Country:US
Mailing Address - Phone:209-476-9474
Mailing Address - Fax:
Practice Address - Street 1:1400 FLORIDA AVE STE 102
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4446
Practice Address - Country:US
Practice Address - Phone:209-573-6147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12332390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program