Provider Demographics
NPI:1700963212
Name:KRISHEN, PRIYA (MD)
Entity Type:Individual
Prefix:
First Name:PRIYA
Middle Name:
Last Name:KRISHEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4970 LAKESHORE RD
Mailing Address - Street 2:FSC
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3539
Mailing Address - Country:US
Mailing Address - Phone:810-385-2803
Mailing Address - Fax:248-423-2576
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:FSC
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-423-2454
Practice Address - Fax:248-423-2576
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079814207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI220F36137OtherBCBSM
MI4685420Medicare ID - Type Unspecified
MI220F36137OtherBCBSM