Provider Demographics
NPI:1609085240
Name:KRISHNAN, KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:KUMAR
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 1:55 FRUIT ST # STREET4
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-724-0578
Mailing Address - Fax:617-724-5997
Practice Address - Street 1:55 FRUIT ST # STREET4
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-0578
Practice Address - Fax:617-724-5997
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121716207R00000X, 207RG0100X
TXQ0093207RG0100X
MA272242207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8EQ228OtherBLUE CROSS BLUE SHIELD
TX8FX432OtherBLUE CROSS BLUE SHIELD
TX340122602Medicaid
TX340122601Medicaid
BP1-0026146OtherINSTITUTIONAL PERMIT
TX340122602Medicaid
TX8FX432OtherBLUE CROSS BLUE SHIELD