Provider Demographics
NPI:1285785154
Name:KRISHNAMOORTHI M. D. INC., A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:KRISHNAMOORTHI M. D. INC., A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:SOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISHNAMOORTHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-838-2278
Mailing Address - Street 1:850 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:ESCALON
Mailing Address - State:CA
Mailing Address - Zip Code:95320-1506
Mailing Address - Country:US
Mailing Address - Phone:209-838-2278
Mailing Address - Fax:
Practice Address - Street 1:850 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:ESCALON
Practice Address - State:CA
Practice Address - Zip Code:95320-1506
Practice Address - Country:US
Practice Address - Phone:209-838-2278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53830HMedicaid
CAZZZ04426ZMedicare ID - Type UnspecifiedMEDICARE GROUP ID
CAH56585Medicare UPIN
CARHM53830HMedicaid
CA00A765620Medicare ID - Type UnspecifiedSOMA KRISHNAMOORTHI MD ID