Provider Demographics
NPI:1396709994
Name:GULASEKARAM, BALASUBRAMANIAM (MD)
Entity type:Individual
Prefix:
First Name:BALASUBRAMANIAM
Middle Name:
Last Name:GULASEKARAM
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 1:17215 STUDEBAKER RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2548
Mailing Address - Country:US
Mailing Address - Phone:562-924-7307
Mailing Address - Fax:562-860-9398
Practice Address - Street 1:17215 STUDEBAKER RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2548
Practice Address - Country:US
Practice Address - Phone:562-924-7307
Practice Address - Fax:562-860-9398
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA354052084B0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A354050Medicaid
CAA35405Medicare ID - Type Unspecified
CA00A354050Medicaid