Provider Demographics
NPI:1033131420
Name:KRISHNAN, SHANTI (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANTI
Middle Name:
Last Name:KRISHNAN
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 1:440 EAST MARSHALL STREET
Mailing Address - Street 2:THIRD FLOOR NORTH. SUITE 300
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380
Mailing Address - Country:US
Mailing Address - Phone:610-436-8611
Mailing Address - Fax:610-436-1193
Practice Address - Street 1:440 EAST MARSHALL STREET
Practice Address - Street 2:THIRD FLOOR NORTH. SUITE 300
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380
Practice Address - Country:US
Practice Address - Phone:610-436-8611
Practice Address - Fax:610-436-1193
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-042214-L208000000X
NJ25-MA-05432500208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001279632Medicaid
PAE55895Medicare UPIN
PA001279632Medicaid