Healthcare Provider Details

I. General information

NPI: 1114970076
Provider Name (Legal Business Name): BRINDA SHREE KRISHNAN M.D.,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 EMELINE AVE
SANTA CRUZ CA
95060-1966
US

IV. Provider business mailing address

1080 EMELINE AVE
SANTA CRUZ CA
95060-1966
US

V. Phone/Fax

Practice location:
  • Phone: 831-454-4100
  • Fax: 831-454-4663
Mailing address:
  • Phone: 831-454-4971
  • Fax: 831-454-4663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD040282
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC141951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: