Basic Information
| Provider Information | |||||||||
| NPI: | 1134180466 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRISHNAMURTHY | ||||||||
| FirstName: | MAHESH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 708610 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840708610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008465313 | ||||||||
| FaxNumber: | 8013529502 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 S 21ST ST | ||||||||
| Address2: | #23 | ||||||||
| City: | EASTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180423851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102504540 | ||||||||
| FaxNumber: | 6102504774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 05/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD426784 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00252667 | 01 | MO | RAIL ROAD MEDICARE | OTHER | 2449108000 | 01 | PA | BCBS | OTHER | 101483129 0001 | 05 | PA | MEDICAID |