Provider Demographics
NPI:1548225139
Name:KRISHNAN, CHANDRASEKHARAN (MD)
Entity Type:Individual
Prefix:
First Name:CHANDRASEKHARAN
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 1:20 ROBINWOOD AVE
Mailing Address - Street 2:APT #2
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 WASHINGTON ST # 450
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:617-636-1183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225169207W00000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAI06017Medicare UPIN
MAA39178Medicare ID - Type Unspecified