Basic Information
| Provider Information | |||||||||
| NPI: | 1932384427 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLI | ||||||||
| FirstName: | KRISHNA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 MARSHALL ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013553353 | ||||||||
| FaxNumber: | 6013553365 | ||||||||
| Practice Location | |||||||||
| Address1: | 1255 HIGHWAY 54 W | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043673014 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2008 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 20021 | MS | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 070119 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 753068151 | 01 | MS | MHP | OTHER | 753068151 | 01 | MS | MPCN | OTHER | P00466198 | 01 | RR MEDICARE | OTHER | 07587759 | 05 | MS | MEDICAID | 300002201 | 01 | MS | US DEPT OF LABOR | OTHER |