Provider Demographics
NPI:1265509665
Name:KRISHNAN, RADHA (MD)
Entity Type:Individual
Prefix:
First Name:RADHA
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 1:1643 E PALMDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-4847
Mailing Address - Country:US
Mailing Address - Phone:661-267-7645
Mailing Address - Fax:661-267-6464
Practice Address - Street 1:1643 E PALMDALE BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4847
Practice Address - Country:US
Practice Address - Phone:661-267-7645
Practice Address - Fax:661-267-6464
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32458174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA87698Medicare UPIN
CAWA32458AMedicare ID - Type Unspecified