Provider Demographics
NPI:1255836631
Name:KRISHNAN, KAVITHA G (MD)
Entity Type:Individual
Prefix:
First Name:KAVITHA
Middle Name:G
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 1:4807 WELFORD DR
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-5333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6810 N MCCORMICK BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-2709
Practice Address - Country:US
Practice Address - Phone:847-674-6900
Practice Address - Fax:773-329-4728
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036156547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program