Healthcare Provider Details

I. General information

NPI: 1942202676
Provider Name (Legal Business Name): KRISHNAN CHALLAPPA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 WOODLAND DR SUITE A
ELIZABETHTOWN KY
42701-2651
US

IV. Provider business mailing address

1324 WOODLAND DR SUITE A
ELIZABETHTOWN KY
42701-2651
US

V. Phone/Fax

Practice location:
  • Phone: 270-765-5921
  • Fax: 270-765-4391
Mailing address:
  • Phone: 270-765-5921
  • Fax: 270-765-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number31956
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number31956
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: