Provider Demographics
NPI:1073521902
Name:KRISHNAN, ANANTH (MD)
Entity Type:Individual
Prefix:DR
First Name:ANANTH
Middle Name:
Last Name:KRISHNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 PEACHWOOD DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-0903
Mailing Address - Country:US
Mailing Address - Phone:386-736-6066
Mailing Address - Fax:386-738-5890
Practice Address - Street 1:665 PEACHWOOD DR
Practice Address - Street 2:SUITE 2
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-0903
Practice Address - Country:US
Practice Address - Phone:386-736-6066
Practice Address - Fax:386-738-5890
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67152207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260726300Medicaid
F87943Medicare UPIN
FL260726300Medicaid