Provider Demographics
NPI:1962594747
Name:MOORTHY, RATHINAM KRISHNA (MD)
Entity type:Individual
Prefix:DR
First Name:RATHINAM
Middle Name:KRISHNA
Last Name:MOORTHY
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 1:301 E ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33594-5253
Mailing Address - Country:US
Mailing Address - Phone:813-689-0331
Mailing Address - Fax:813-653-1752
Practice Address - Street 1:301 E ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33594-5253
Practice Address - Country:US
Practice Address - Phone:813-689-0331
Practice Address - Fax:813-653-1752
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0040574207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067882100Medicaid
D54048Medicare UPIN
FL067882100Medicaid