Provider Demographics
NPI:1023047198
Name:KRISHNAN, SUBBARAYAN (MD)
Entity type:Individual
Prefix:
First Name:SUBBARAYAN
Middle Name:
Last Name:KRISHNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:S.
Other - Middle Name:
Other - Last Name:KRISHNAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, INC
Mailing Address - Street 1:1850 W FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-3718
Mailing Address - Country:US
Mailing Address - Phone:951-438-2200
Mailing Address - Fax:909-605-8160
Practice Address - Street 1:1850 W FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-3718
Practice Address - Country:US
Practice Address - Phone:951-438-2200
Practice Address - Fax:909-605-8160
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA054481207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A544810OtherPTAN
CA00A544810Medicaid
CA00A544810Medicaid
CAG18844Medicare UPIN