Basic Information
| Provider Information | |||||||||
| NPI: | 1235217357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALASUBRAMANIAN | ||||||||
| FirstName: | MAHESWARI | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 255228 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958655228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2801 K ST | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167333777 | ||||||||
| FaxNumber: | 9164546780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 10258 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | A96252 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A962520 | 05 | CA | MEDICAID | 002018658 | 05 | NV | MEDICAID |