Healthcare Provider Details

I. General information

NPI: 1922126887
Provider Name (Legal Business Name): KRISHNA S VARA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 04/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 S WICKHAM RD # 101
W.MELBOURNE FL
32904-1123
US

IV. Provider business mailing address

395 S WICKHAM RD # 101
W.MELBOURNE FL
32904-1123
US

V. Phone/Fax

Practice location:
  • Phone: 321-953-9981
  • Fax: 321-953-0219
Mailing address:
  • Phone: 321-953-9981
  • Fax: 321-953-0219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME88505
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberME88505
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: