Basic Information
| Provider Information | |||||||||
| NPI: | 1588625099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRISHNAMACHARY | ||||||||
| FirstName: | MOHAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704953396 | ||||||||
| FaxNumber: | 7704952307 | ||||||||
| Practice Location | |||||||||
| Address1: | 6300 HOSPITAL PKWY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JOHNS CREEK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300971828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706238965 | ||||||||
| FaxNumber: | 7706234018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2006 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 47934 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | 057094 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 003121786E | 05 | GA | MEDICAID | 003121786F | 05 | GA | MEDICAID |