Provider Demographics
NPI:1235107673
Name:GANNAMANENI, KRISHNA (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:
Last Name:GANNAMANENI
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 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:1345 UNITY PL STE 110
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5768
Practice Address - Country:US
Practice Address - Phone:765-807-2787
Practice Address - Fax:765-807-2789
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059023A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200486540AMedicaid
IN200486540AMedicaid
INZN5040Medicare PIN
INH20849Medicare UPIN