1518490069 NPI number — DR. VIKRAM ADITYA BALA DPM

Table of content: DR. VIKRAM ADITYA BALA DPM (NPI 1518490069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518490069 NPI number — DR. VIKRAM ADITYA BALA DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALA
Provider First Name:
VIKRAM
Provider Middle Name:
ADITYA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518490069
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5911 TIMUQUANA RD UNIT 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32210-7897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-251-5053
Provider Business Mailing Address Fax Number:
904-224-2002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1914 SOUTHSIDE BLVD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-1997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-726-9901
Provider Business Practice Location Address Fax Number:
904-224-2002
Provider Enumeration Date:
04/11/2017

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: 213ES0103X , with the licence number:  PO4143 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 111281400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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