Provider Demographics
NPI:1194578260
Name:BATHINA, KRISHNA SASANKA (MD)
Entity type:Individual
Prefix:DR
First Name:KRISHNA
Middle Name:SASANKA
Last Name:BATHINA
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 1:815 MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1080
Mailing Address - Country:US
Mailing Address - Phone:309-672-4977
Mailing Address - Fax:
Practice Address - Street 1:815 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1080
Practice Address - Country:US
Practice Address - Phone:309-672-4977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125083918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine