Provider Demographics
NPI:1952352734
Name:VENUGOPAL, BALA (MD)
Entity Type:Individual
Prefix:DR
First Name:BALA
Middle Name:
Last Name:VENUGOPAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BALASUBRAMANIAN
Other - Middle Name:
Other - Last Name:VENUGOPAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD,
Mailing Address - Street 1:75 REMITTANCE DR
Mailing Address - Street 2:DEPT 6008
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-6008
Mailing Address - Country:US
Mailing Address - Phone:562-282-1419
Mailing Address - Fax:562-920-4642
Practice Address - Street 1:11480 BROOKSHIRE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-5026
Practice Address - Country:US
Practice Address - Phone:562-862-2775
Practice Address - Fax:562-904-8035
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67362208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A673620Medicaid
A67362OtherDEA
CABV6169533OtherDEA NUMBER
CABJ454VMedicare PIN
CABV6169533OtherDEA NUMBER