Provider Demographics
NPI:1588014393
Name:PEDDADA, KRISHI VENKATA (MD)
Entity Type:Individual
Prefix:
First Name:KRISHI
Middle Name:VENKATA
Last Name:PEDDADA
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 1:360 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3111
Mailing Address - Country:US
Mailing Address - Phone:470-359-9618
Mailing Address - Fax:
Practice Address - Street 1:273 HARRISON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-7132
Practice Address - Country:US
Practice Address - Phone:864-654-6706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87529207W00000X
VA0101269064207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology