Provider Demographics
NPI:1922126887
Name:VARA, KRISHNA S (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:S
Last Name:VARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 S WICKHAM RD
Mailing Address - Street 2:# 101
Mailing Address - City:W.MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1123
Mailing Address - Country:US
Mailing Address - Phone:321-953-9981
Mailing Address - Fax:321-953-0219
Practice Address - Street 1:395 S WICKHAM RD
Practice Address - Street 2:# 101
Practice Address - City:W.MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1123
Practice Address - Country:US
Practice Address - Phone:321-953-9981
Practice Address - Fax:321-953-0219
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88505207Q00000X, 2083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL244144Medicaid
F88288Medicare UPIN
37520Medicare ID - Type Unspecified