Provider Demographics
NPI:1396754636
Name:BALAKUMARAN, GOWTHAMY (MD)
Entity type:Individual
Prefix:DR
First Name:GOWTHAMY
Middle Name:
Last Name:BALAKUMARAN
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 1:3676 JUPITER AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-1941
Mailing Address - Country:US
Mailing Address - Phone:805-733-9515
Mailing Address - Fax:
Practice Address - Street 1:301 N R ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-5226
Practice Address - Country:US
Practice Address - Phone:805-737-6400
Practice Address - Fax:805-737-6430
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67113208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A671130Medicaid
CAA67113OtherMED LICENSE
H99312Medicare UPIN