Provider Demographics
NPI:1356391569
Name:KISHAN, KISHAN T (MD)
Entity type:Individual
Prefix:DR
First Name:KISHAN
Middle Name:T
Last Name:KISHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2219 DUBOIS DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3212
Mailing Address - Country:US
Mailing Address - Phone:574-269-3420
Mailing Address - Fax:574-269-2234
Practice Address - Street 1:2219 DUBOIS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3212
Practice Address - Country:US
Practice Address - Phone:574-269-3420
Practice Address - Fax:574-269-2234
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ01036480A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100088150Medicaid
IN100088150Medicaid
INWA459310BMedicare PIN