1184245516 NPI number — DR. BALAJI PRASAD ELLAPP MOHANAKRISHNAN MD

Table of content: DR. BALAJI PRASAD ELLAPP MOHANAKRISHNAN MD (NPI 1184245516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184245516 NPI number — DR. BALAJI PRASAD ELLAPP MOHANAKRISHNAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOHANAKRISHNAN
Provider First Name:
BALAJI PRASAD ELLAPP
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KRISH
Provider Other First Name:
B
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1184245516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11234 ANDERSON STREET
Provider Second Line Business Mailing Address:
MC 1503A, PCCM DEPARTMENT
Provider Business Mailing Address City Name:
LOMA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-414-9100
Provider Business Mailing Address Fax Number:
412-987-6877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 S. COULTER STREET
Provider Second Line Business Practice Location Address:
SUITE 2500
Provider Business Practice Location Address City Name:
AMARILLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79106-1786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-414-9100
Provider Business Practice Location Address Fax Number:
806-354-5717
Provider Enumeration Date:
04/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  186672 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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