Provider Demographics
NPI:1154354769
Name:KRISHNA, HARSHAVARDHAN R (MD)
Entity type:Individual
Prefix:
First Name:HARSHAVARDHAN
Middle Name:R
Last Name:KRISHNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12123 CONANT ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-2718
Mailing Address - Country:US
Mailing Address - Phone:313-891-1500
Mailing Address - Fax:313-891-1599
Practice Address - Street 1:12123 CONANT ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-2718
Practice Address - Country:US
Practice Address - Phone:313-891-1500
Practice Address - Fax:313-891-1599
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070833207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-4521365Medicaid
MI0P19440-001Medicare ID - Type Unspecified
MI10-4521365Medicaid