Provider Demographics
NPI:1184625063
Name:KRISHNAN, VIJAY KUMAR (MD)
Entity type:Individual
Prefix:
First Name:VIJAY
Middle Name:KUMAR
Last Name:KRISHNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5312
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77726-5312
Mailing Address - Country:US
Mailing Address - Phone:409-838-0411
Mailing Address - Fax:409-838-9032
Practice Address - Street 1:3420 FANNIN ST
Practice Address - Street 2:SUITE 190
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-3809
Practice Address - Country:US
Practice Address - Phone:409-838-0411
Practice Address - Fax:409-838-9032
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8712207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120425701Medicaid
TX120425701Medicaid