Provider Demographics
NPI:1851364699
Name:BOBBILI, KRISHNA K (MD)
Entity type:Individual
Prefix:
First Name:KRISHNA
Middle Name:K
Last Name:BOBBILI
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:2414 KOHLER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3129
Practice Address - Country:US
Practice Address - Phone:920-457-4461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-00533207R00000X
TXN5578207RI0200X
ND2005-00533208M00000X
WI4425207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0053BMedicaid
WI100281717Medicaid
NC5901740Medicaid
NC5901740Medicaid