Provider Demographics
NPI:1851364699
Name:BOBBILI, KRISHNA K (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:K
Last Name:BOBBILI
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 1:11803 SOUTH FWY STE 111
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7028
Mailing Address - Country:US
Mailing Address - Phone:817-349-9500
Mailing Address - Fax:817-349-9501
Practice Address - Street 1:11803 SOUTH FWY STE 111
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7028
Practice Address - Country:US
Practice Address - Phone:817-349-9500
Practice Address - Fax:817-349-9501
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5578207RI0200X
NC2005-00533207R00000X
ND2005-00533208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0053BMedicaid
NC5901740Medicaid
NC2045166Medicare PIN
NC5901740Medicaid