Provider Demographics
NPI:1699067132
Name:KRISHNAN, GEETHA PRIYDARSHINI (MD)
Entity type:Individual
Prefix:
First Name:GEETHA
Middle Name:PRIYDARSHINI
Last Name:KRISHNAN
Suffix:
Gender:F
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:N2950 STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2655
Mailing Address - Country:US
Mailing Address - Phone:262-245-0535
Mailing Address - Fax:262-245-2248
Practice Address - Street 1:N2950 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2655
Practice Address - Country:US
Practice Address - Phone:262-245-0535
Practice Address - Fax:262-245-2248
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT62300207P00000X
WI60129-20207P00000X
IL036.128889207P00000X
LA321104207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036128889 2Medicaid
WI1699067132OtherBCBSWI
WIKRISHGEEOtherMERCYCARE INSURANCE
WI1699067132Medicaid
WI541760967Medicare PIN