Provider Demographics
NPI:1316098205
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:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISHNAMOORTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISHNAMOORTHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-874-2321
Mailing Address - Street 1:324 F ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CA
Mailing Address - Zip Code:95386-9013
Mailing Address - Country:US
Mailing Address - Phone:209-874-2321
Mailing Address - Fax:209-874-3896
Practice Address - Street 1:324 F ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CA
Practice Address - Zip Code:95386-9013
Practice Address - Country:US
Practice Address - Phone:209-874-2321
Practice Address - Fax:209-874-3896
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
CA00A708970Medicaid
CARHM53829HMedicaid
CA553829Medicare ID - Type UnspecifiedRHC
CAH24617Medicare UPIN
CAZZZ04426ZMedicare ID - Type UnspecifiedMEDICARE GROUP ID