Provider Demographics
NPI:1891786554
Name:KRISHNATHAS, ANANTHAN (MD)
Entity Type:Individual
Prefix:MR
First Name:ANANTHAN
Middle Name:
Last Name:KRISHNATHAS
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 1:4605 MACCORKLE AVE. SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309
Mailing Address - Country:US
Mailing Address - Phone:304-766-3526
Mailing Address - Fax:
Practice Address - Street 1:4605 MACCORKLE AVE. SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309
Practice Address - Country:US
Practice Address - Phone:304-766-3526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21702207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000987Medicaid
WV3810000987Medicaid
WVKR4145861Medicare ID - Type Unspecified