Healthcare Provider Details

I. General information

NPI: 1407958390
Provider Name (Legal Business Name): MIGUEL KRISHNAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 11/18/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST SUITE 2592
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

PO BOX 235
LOMA LINDA CA
92354-0235
US

V. Phone/Fax

Practice location:
  • Phone: 772-618-9714
  • Fax: 772-618-9714
Mailing address:
  • Phone: 772-618-9714
  • Fax: 772-618-9714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number20A8996
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: