Provider Demographics
NPI:1043456148
Name:KRISH, RACHNA A (MD)
Entity Type:Individual
Prefix:
First Name:RACHNA
Middle Name:A
Last Name:KRISH
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 1:13241 BARTRAM PARK BLVD
Mailing Address - Street 2:SUITE # 209
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5212
Mailing Address - Country:US
Mailing Address - Phone:904-242-4220
Mailing Address - Fax:904-551-1502
Practice Address - Street 1:13241 BARTRAM PARK BLVD
Practice Address - Street 2:SUITE # 209
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5212
Practice Address - Country:US
Practice Address - Phone:904-242-4220
Practice Address - Fax:904-551-1502
Is Sole Proprietor?:No
Enumeration Date:2008-12-20
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME11521192080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010557300Medicaid
NY03344456Medicaid