Provider Demographics
NPI:1215021696
Name:LINGALA, KRISHNA K (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:K
Last Name:LINGALA
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:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9347
Mailing Address - Country:US
Mailing Address - Phone:575-356-6652
Mailing Address - Fax:575-226-0099
Practice Address - Street 1:42121 US HWY 70
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-9347
Practice Address - Country:US
Practice Address - Phone:575-356-6652
Practice Address - Fax:575-226-0099
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD20040760208100000X
NMMD2004-0760208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM25604368Medicaid
I37790Medicare UPIN
344523606Medicare ID - Type Unspecified
NM25604368Medicaid
MN302226Medicare PIN