Healthcare Provider Details

I. General information

NPI: 1568709657
Provider Name (Legal Business Name): KISHORE NALLU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 07/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 W MARKET ST STE 2K
LIMA OH
45801-4602
US

IV. Provider business mailing address

PO BOX 636930
CINCINNATI OH
45263-6930
US

V. Phone/Fax

Practice location:
  • Phone: 419-996-5852
  • Fax: 419-996-5854
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number53627
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35131382
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: