Provider Demographics
NPI:1154382703
Name:BALAGURU, DURAISAMY (MD)
Entity type:Individual
Prefix:DR
First Name:DURAISAMY
Middle Name:
Last Name:BALAGURU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 WASHINGTON ST
Mailing Address - Street 2:NEMC# 313
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1526
Mailing Address - Country:US
Mailing Address - Phone:617-636-7435
Mailing Address - Fax:
Practice Address - Street 1:750 WASHINGTON ST
Practice Address - Street 2:NEMC# 313
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1526
Practice Address - Country:US
Practice Address - Phone:617-636-7435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2097342080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0173380Medicaid
MA0173380Medicaid
MAH62798Medicare UPIN