Provider Demographics
NPI:1689644528
Name:KISHAN, SHYAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SHYAM
Middle Name:
Last Name:KISHAN
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 1:4128 FAIR MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5680 FRISCO SQUARE BLVD STE 2500
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-3315
Practice Address - Country:US
Practice Address - Phone:972-347-4783
Practice Address - Fax:972-347-4916
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068071A207X00000X, 207XP3100X
TXR1799207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000674113OtherANTHEM PIN
IN200994100Medicaid
TX375540701Medicaid
I62118Medicare UPIN
INP01174673Medicare PIN