Provider Demographics
NPI:1275515728
Name:KRISHNAN, MADHAVAN (MD)
Entity Type:Individual
Prefix:
First Name:MADHAVAN
Middle Name:
Last Name:KRISHNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:27758 SANTA MARGARITA PKWY
Mailing Address - Street 2:#409
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6709
Mailing Address - Country:US
Mailing Address - Phone:949-583-9264
Mailing Address - Fax:949-269-9139
Practice Address - Street 1:27725 SANTA MARGARITA PKWY
Practice Address - Street 2:STE 101
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6704
Practice Address - Country:US
Practice Address - Phone:949-462-3999
Practice Address - Fax:949-462-3777
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-08-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA875022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I16267Medicare UPIN