Provider Demographics
NPI:1013011055
Name:KRISHNAMOORTHI, SOMA (MD)
Entity Type:Individual
Prefix:
First Name:SOMA
Middle Name:
Last Name:KRISHNAMOORTHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W CALIFORNIA STREET
Mailing Address - Street 2:
Mailing Address - City:ESCALON
Mailing Address - State:CA
Mailing Address - Zip Code:95320-1506
Mailing Address - Country:US
Mailing Address - Phone:209-838-2278
Mailing Address - Fax:209-525-3124
Practice Address - Street 1:850 W CALIFORNIA STREET
Practice Address - Street 2:
Practice Address - City:ESCALON
Practice Address - State:CA
Practice Address - Zip Code:95320-1506
Practice Address - Country:US
Practice Address - Phone:209-838-2278
Practice Address - Fax:209-525-3124
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76562207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53830HMedicaid
CA553830Medicare ID - Type UnspecifiedGROUP RIVERBEND ID
CA00A765620Medicare ID - Type UnspecifiedPERSONAL ID
CAGR0104660Medicare ID - Type UnspecifiedGRP MEDICAL ID
CAZZZ04426ZMedicare ID - Type UnspecifiedGROUP MEDICARE ID
CAH56585Medicare UPIN