Provider Demographics
NPI:1275822256
Name:KRISHNAN, NISHA BALA (DPM)
Entity Type:Individual
Prefix:DR
First Name:NISHA
Middle Name:BALA
Last Name:KRISHNAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 N LECANTO HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-3569
Mailing Address - Country:US
Mailing Address - Phone:352-513-4867
Mailing Address - Fax:888-314-9873
Practice Address - Street 1:3404 N LECANTO HWY
Practice Address - Street 2:SUITE A
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3569
Practice Address - Country:US
Practice Address - Phone:352-513-4867
Practice Address - Fax:888-314-9873
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTO BE DETERMINED213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPO3609OtherLICENSE