Provider Demographics
NPI:1922054345
Name:KRISHNADAS, PRAVEEN (MD)
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:
Last Name:KRISHNADAS
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 1:3201 MEDICAL WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-5412
Mailing Address - Country:US
Mailing Address - Phone:863-382-0770
Mailing Address - Fax:863-471-9968
Practice Address - Street 1:3201 MEDICAL WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-5412
Practice Address - Country:US
Practice Address - Phone:863-382-0770
Practice Address - Fax:863-471-9968
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME83409208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266227200Medicaid
FL47941OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FLH79281Medicare UPIN