Healthcare Provider Details

I. General information

NPI: 1508540667
Provider Name (Legal Business Name): KRISHNA SHAKTI KAPOOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 4TH ST N
FARGO ND
58102-4539
US

IV. Provider business mailing address

419 3RD ST N APT 216
FARGO ND
58102-5458
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-6161
  • Fax:
Mailing address:
  • Phone: 512-717-1210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPT24339
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: