Provider Demographics
NPI:1790723625
Name:KRISHNAMOORTHY, GEETHA (MD)
Entity type:Individual
Prefix:
First Name:GEETHA
Middle Name:
Last Name:KRISHNAMOORTHY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR # J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:
Practice Address - Street 1:44428 WOODWARD AVE STE 102
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5009
Practice Address - Country:US
Practice Address - Phone:248-858-3126
Practice Address - Fax:248-858-6499
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062031207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG53324OtherHAP ID
MI110F336360OtherBCBSM
MI1346398971OtherGROUP NPI
MI205485614OtherTAX ID
MI3347713Medicaid
MI4301062031OtherLICENSE
MI4301062031OtherLICENSE
MI0P41360002Medicare PIN