Provider Demographics
NPI:1942203906
Name:KISHAN, CHANNARAYAPATNA V (MD)
Entity Type:Individual
Prefix:
First Name:CHANNARAYAPATNA
Middle Name:V
Last Name:KISHAN
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:PO BOX 829641
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-9641
Mailing Address - Country:US
Mailing Address - Phone:267-370-5296
Mailing Address - Fax:215-230-3725
Practice Address - Street 1:821 HUNTINGDON PIKE STE 150
Practice Address - Street 2:
Practice Address - City:HUNTINGDON VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19006-8369
Practice Address - Country:US
Practice Address - Phone:267-627-6715
Practice Address - Fax:267-627-6717
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066331L207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019007840001Medicaid
PAH65414Medicare UPIN
PA0019007840001Medicaid