Basic Information
| Provider Information | |||||||||
| NPI: | 1790795441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRISHNA KUMAR | ||||||||
| FirstName: | GAYATHRI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2620 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192556721 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 N JUDD PKWY NE | ||||||||
| Address2: | |||||||||
| City: | FUQUAY VARINA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275262367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195571110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 09/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2014-01777 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 28701 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 287013 | 05 | SC | MEDICAID |