Basic Information
| Provider Information | |||||||||
| NPI: | 1710195201 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ATHOTA | ||||||||
| FirstName: | KRISHNA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 BURNET AVE | ||||||||
| Address2: | 3 SOUTH CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758787 | ||||||||
| FaxNumber: | 5134757348 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 GOODMAN ST | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758787 | ||||||||
| FaxNumber: | 5134757348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 01/08/2015 | ||||||||
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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 | 208600000X | 4301078386 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 35090845 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 35090845 | OH | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | 35090845 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2811229 | 05 | OH | MEDICAID | 7100059370 | 05 | KY | MEDICAID | 200908710 | 05 | IN | MEDICAID |