Provider Demographics
NPI:1548231749
Name:KRISHNAN, AMBUJAM R (MD)
Entity Type:Individual
Prefix:DR
First Name:AMBUJAM
Middle Name:R
Last Name:KRISHNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15645 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-2851
Mailing Address - Country:US
Mailing Address - Phone:734-464-7600
Mailing Address - Fax:734-464-9797
Practice Address - Street 1:15645 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-2851
Practice Address - Country:US
Practice Address - Phone:734-464-7600
Practice Address - Fax:734-464-9797
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIAK043104207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1783169Medicaid
MI0N90400001Medicare PIN
MI1783169Medicaid