Provider Demographics
NPI:1770608630
Name:GADDAM, KRISHNA KISHORE (MD)
Entity type:Individual
Prefix:DR
First Name:KRISHNA
Middle Name:KISHORE
Last Name:GADDAM
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 1:1022 1ST ST N STE 500
Mailing Address - Street 2:
Mailing Address - City:ALABASTER
Mailing Address - State:AL
Mailing Address - Zip Code:35007-8740
Mailing Address - Country:US
Mailing Address - Phone:205-663-5775
Mailing Address - Fax:205-664-2112
Practice Address - Street 1:1022 1ST ST N STE 500
Practice Address - Street 2:
Practice Address - City:ALABASTER
Practice Address - State:AL
Practice Address - Zip Code:35007-8740
Practice Address - Country:US
Practice Address - Phone:205-663-5775
Practice Address - Fax:205-664-2112
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26807207RC0000X
LAMD.202424207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL165669Medicaid
AL165669Medicaid
LA1318027Medicaid
ALBG9513284OtherFEDERAL DEA NUMBER
LA4N4907061Medicare PIN
MS04379016Medicaid