Provider Demographics
NPI:1942319934
Name:NAMBURI, KRISHNA MOHAN (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:MOHAN
Last Name:NAMBURI
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 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-242-3175
Mailing Address - Fax:812-242-3543
Practice Address - Street 1:1429 N 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1037
Practice Address - Country:US
Practice Address - Phone:812-242-3175
Practice Address - Fax:812-242-3543
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038133A207RC0000X
IL36077615207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100376520ZMedicaid
P00398470OtherRAILROAD MEDICARE
INP00844276OtherRAILROAD MEDICARE
IN100376520GOtherMOLINA HEALTHCARE MCAID
IN100376520Medicaid
351904269237OtherCARESOURCE MEDICAID
060023841OtherRAILROAD MCARE PALAMETTO
IN100376520YMedicaid
000000089624OtherANTHEM
IN060068542OtherRAILROAD MEDICARE
IN100376520AOtherMOLINA HEALTHCARE MCAID
351904269124OtherCARESOURCE MEDICAID
4589941OtherAETNA
ILP01056435OtherRAILROAD MEDICARE
IN859910LLMedicare PIN
IN841040HMedicare PIN
IN148010CMedicare PIN
P00398470OtherRAILROAD MEDICARE
IN100376520AOtherMOLINA HEALTHCARE MCAID
060023841OtherRAILROAD MCARE PALAMETTO
INP00844276OtherRAILROAD MEDICARE
IN100376520ZMedicaid
ILK06358Medicare PIN
IN192770SSMedicare PIN