Basic Information
| Provider Information | |||||||||
| NPI: | 1538205539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALUJA | ||||||||
| FirstName: | VIVEK | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| OtherLastName: | BALUJA | ||||||||
| OtherFirstName: | VIVEK | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9110 COLLEGE POINTE CT # MC845 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339193244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392082212 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 35 MICHIGAN ST NE | ||||||||
| Address2: | SUITE 3003 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162672500 | ||||||||
| FaxNumber: | 6162672501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0008X | 4301102633 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 2080P0008X | P20581 | MD | N | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 2084N0400X | MED-PHYS-LIC-76853 | MT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 18778 | NH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 14954 | ND | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 26126 | MS | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD191107 | OR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 35.132402 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | TM00763 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 4301102633 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | ME132291 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1538205539 | 05 | MI | MEDICAID | 3116042 | 05 | NH | MEDICAID | 62004271 | 05 | CO | MEDICAID |