Basic Information
| Provider Information | |||||||||
| NPI: | 1295872927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALAGOPAL | ||||||||
| FirstName: | ASHWIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6201 GREENLEIGH AVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLE RIVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212202004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109336423 | ||||||||
| FaxNumber: | 4105004266 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 E MONUMENT ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212870027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109551725 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 35085045 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | D69548 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207R00000X | D69548 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 417955200 | 05 | MD | MEDICAID |