Provider Demographics
NPI:1932384427
Name:GOLI, KRISHNA J (MD)
Entity Type:Individual
Prefix:
First Name:KRISHNA
Middle Name:J
Last Name:GOLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MARSHALL ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1651
Mailing Address - Country:US
Mailing Address - Phone:601-355-3353
Mailing Address - Fax:601-355-3365
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:404-367-3014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS200212084N0400X
GA0701192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS753068151OtherMHP
MS753068151OtherMPCN
P00466198OtherRR MEDICARE
MS07587759Medicaid
MS300002201OtherUS DEPT OF LABOR
MS07587759Medicaid
P00466198OtherRR MEDICARE