Provider Demographics
NPI:1477565851
Name:KRISHNAN, SANJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
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 1:2 BLACKBERRY WAY UNIT 309
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-7199
Mailing Address - Country:US
Mailing Address - Phone:602-881-5515
Mailing Address - Fax:
Practice Address - Street 1:195 DOVER POINT RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-9147
Practice Address - Country:US
Practice Address - Phone:603-742-2612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301116248207R00000X
AZ34277207R00000X
NH19139207RG0300X, 207RH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3114972Medicaid
AZ947385Medicaid
AZI36798Medicare UPIN
Z90968Medicare PIN