Basic Information
| Provider Information | |||||||||
| NPI: | 1770776510 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRISHNAMURTHY | ||||||||
| FirstName: | VIDHYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2195 CLUB CENTER DR | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924084170 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2195 CLUB CENTER DR STE A | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924084162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2007 | ||||||||
| LastUpdateDate: | 01/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PSY24993 | CA | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC2200X | PSY24993 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.