Provider Demographics
NPI:1568709657
Name:NALLU, KISHORE (MD)
Entity Type:Individual
Prefix:
First Name:KISHORE
Middle Name:
Last Name:NALLU
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:PO BOX 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 W MARKET ST STE 2K
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4602
Practice Address - Country:US
Practice Address - Phone:419-996-5852
Practice Address - Fax:419-996-5854
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53627207R00000X
OH35131382207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine