Provider Demographics
NPI:1588769350
Name:BALAKRISHNAN, VELUKUTTY (MD)
Entity type:Individual
Prefix:
First Name:VELUKUTTY
Middle Name:
Last Name:BALAKRISHNAN
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 1:105 N OSCEOLA AVE
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34450-4119
Mailing Address - Country:US
Mailing Address - Phone:352-344-2440
Mailing Address - Fax:352-344-2448
Practice Address - Street 1:105 N OSCEOLA AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34450-4119
Practice Address - Country:US
Practice Address - Phone:352-344-2440
Practice Address - Fax:352-344-2448
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 43309207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068812600Medicaid
63314OtherGHI
D21253Medicare UPIN
FL068812600Medicaid