Provider Demographics
NPI:1710195201
Name:ATHOTA, KRISHNA (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:
Last Name:ATHOTA
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 1:3200 BURNET AVE
Mailing Address - Street 2:3 SOUTH CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3019
Mailing Address - Country:US
Mailing Address - Phone:513-475-8787
Mailing Address - Fax:513-475-7348
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-475-8787
Practice Address - Fax:513-475-7348
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078386208600000X
OH35090845208600000X, 2086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2811229Medicaid
KY7100059370Medicaid
IN200908710Medicaid
OH2811229Medicaid