Provider Demographics
NPI:1659331734
Name:KRISHNAN, KALYAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:KALYAN
Middle Name:S
Last Name:KRISHNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-3034
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:115 WOODBINE LANE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-5208
Practice Address - Country:US
Practice Address - Phone:570-271-6621
Practice Address - Fax:570-271-5655
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036819L207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00691008Medicaid
PA058976Medicare ID - Type Unspecified
PA00691008Medicaid