Provider Demographics
NPI:1407958390
Name:KRISHNAN, MIGUEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:
Last Name:KRISHNAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0235
Mailing Address - Country:US
Mailing Address - Phone:772-618-9714
Mailing Address - Fax:772-618-9714
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:SUITE 2592
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:772-618-9714
Practice Address - Fax:772-618-9714
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8996207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX89960Medicaid
CAH39022Medicare UPIN