Healthcare Provider Details

I. General information

NPI: 1316098205
Provider Name (Legal Business Name): KRISHNAMOORTHI M. D. INC., A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 03/22/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 F ST
WATERFORD CA
95386-9013
US

IV. Provider business mailing address

324 F ST
WATERFORD CA
95386-9013
US

V. Phone/Fax

Practice location:
  • Phone: 209-874-2321
  • Fax: 209-874-3896
Mailing address:
  • Phone: 209-874-2321
  • Fax: 209-874-3896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISHNAMOORTHI KRISHNAMOORTHI
Title or Position: CEO
Credential: M.D.
Phone: 209-874-2321