Provider Demographics
NPI:1508829284
Name:PERSAUD, KRISHNA VIJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISHNA
Middle Name:VIJAY
Last Name:PERSAUD
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 1:4418 E RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589-9375
Mailing Address - Country:US
Mailing Address - Phone:315-589-4641
Mailing Address - Fax:315-589-9585
Practice Address - Street 1:4418 E RIDGE RD
Practice Address - Street 2:WILLIAMSON MEDICAL PLLC
Practice Address - City:WILLIAMSON
Practice Address - State:NY
Practice Address - Zip Code:14589-9375
Practice Address - Country:US
Practice Address - Phone:315-589-4641
Practice Address - Fax:315-589-9585
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205585207K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01535859Medicaid
NY102914AAOtherPREFERRED CARE ALLERGY
NY102914BJOtherPREFERRED CARE IM
NY030000058OtherBLUE CHOICE ALLERGY
NY010000058OtherBLUE CHOICE IM
NY010000058OtherBLUE CHOICE IM
NY01535859Medicaid