Provider Demographics
NPI:1568495711
Name:KRISHNAMURTHY, SMITA (MD)
Entity Type:Individual
Prefix:
First Name:SMITA
Middle Name:
Last Name:KRISHNAMURTHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45435-0001
Mailing Address - Country:US
Mailing Address - Phone:937-245-7100
Mailing Address - Fax:937-245-7999
Practice Address - Street 1:3640 COLONEL GLENN HWY
Practice Address - Street 2:140 WHITE HALL
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45435-0001
Practice Address - Country:US
Practice Address - Phone:937-775-2625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006013744207ZP0102X
MN104955207ZP0105X
MN53377207ZP0105X
OH099881207ZD0900X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
IAENROLLEDMedicaid