Provider Demographics
NPI:1548292303
Name:BALAKRISHNAN, AMARAVATHI (MD)
Entity type:Individual
Prefix:MRS
First Name:AMARAVATHI
Middle Name:
Last Name:BALAKRISHNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 N JACKSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1925
Mailing Address - Country:US
Mailing Address - Phone:408-259-1250
Mailing Address - Fax:408-259-7439
Practice Address - Street 1:155 N JACKSON AVE STE 101
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1925
Practice Address - Country:US
Practice Address - Phone:408-259-1250
Practice Address - Fax:408-259-7439
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30274208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A302740Medicaid
CA942643197OtherTAX ID/EIN