Provider Demographics
NPI:1316100258
Name:BALLA, SUDARSHAN (MD)
Entity type:Individual
Prefix:
First Name:SUDARSHAN
Middle Name:
Last Name:BALLA
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 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-1200
Mailing Address - Country:US
Mailing Address - Phone:304-598-4000
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPTIAL DR
Practice Address - Street 2:DC095
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212
Practice Address - Country:US
Practice Address - Phone:573-884-2123
Practice Address - Fax:573-884-2168
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008013469207R00000X
WV27816207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine