Provider Demographics
NPI:1932395811
Name:BALAMUTHUSAMY, SARAVANAN (MD)
Entity type:Individual
Prefix:DR
First Name:SARAVANAN
Middle Name:
Last Name:BALAMUTHUSAMY
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 1:1000 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3029
Mailing Address - Country:US
Mailing Address - Phone:817-877-5858
Mailing Address - Fax:817-335-4418
Practice Address - Street 1:1001 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2228
Practice Address - Country:US
Practice Address - Phone:817-877-5858
Practice Address - Fax:817-335-4418
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201657207R00000X
TXQ2427207R00000X, 207RN0300X
MS20565207RN0300X
AZ43632207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX342884901Medicaid
TX387898YSE6Medicare PIN