Provider Demographics
NPI:1790723625
Name:KRISHNAMOORTHY, GEETHA (MD)
Entity Type:Individual
Prefix:
First Name:GEETHA
Middle Name:
Last Name:KRISHNAMOORTHY
Suffix:
Gender:F
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:PO BOX 674147
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-4147
Mailing Address - Country:US
Mailing Address - Phone:248-354-4709
Mailing Address - Fax:248-354-4807
Practice Address - Street 1:28411 NORTHWESTERN HWY
Practice Address - Street 2:SUITE # 200
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-5544
Practice Address - Country:US
Practice Address - Phone:248-354-4709
Practice Address - Fax:248-354-4807
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062031207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1346398971OtherGROUP NPI
MI4301062031OtherLICENSE
MI110F336360OtherBCBSM
MI205485614OtherTAX ID
MI3347713Medicaid
MIG53324OtherHAP ID
MI4301062031OtherLICENSE
MI0P41360002Medicare PIN