Individual
UTHAM P BALACHANDRAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
444 W FORT ST FL 2, BOISE, ID 83702-4535
(208) 422-1018
Mailing address
15933 CLAYTON RD STE 201, BALLWIN, MO 63011-2172
(636) 200-4393
(636) 527-0838
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2015003345
MO
152W00000X
Optometrist
OEG002829
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12564335
CAQH PROVIDER NUMBER
PA
Enumeration date
07/17/2013
Last updated
06/23/2023
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