Provider Demographics
NPI:1407099575
Name:KRISHNASAMY, KAVITA PERUMAL (MD)
Entity Type:Individual
Prefix:
First Name:KAVITA
Middle Name:PERUMAL
Last Name:KRISHNASAMY
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 1:1267 HIGHWAY 54 W STE 4100
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2112
Mailing Address - Country:US
Mailing Address - Phone:770-506-5470
Mailing Address - Fax:770-506-5471
Practice Address - Street 1:1267 HIGHWAY 54 W STE 4100
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2112
Practice Address - Country:US
Practice Address - Phone:770-506-5470
Practice Address - Fax:770-506-5471
Is Sole Proprietor?:No
Enumeration Date:2009-04-19
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA83131207RC0001X
MI4301106823207RC0000X, 207RC0001X
FLME132529207RC0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021336400Medicaid
FLJA361ZOtherMEDICARE