Healthcare Provider Details

I. General information

NPI: 1720095458
Provider Name (Legal Business Name): KRISHEN KESAV NAYAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 ADMIRAL PEARY HIGHWAY EBENSBURG CENTER
EBENSBURG PA
15931-0600
US

IV. Provider business mailing address

214 COLLEGE PARK PLAZA
JOHNSTOWN PA
15904-2833
US

V. Phone/Fax

Practice location:
  • Phone: 814-472-0226
  • Fax: 814-472-8624
Mailing address:
  • Phone: 814-262-0025
  • Fax: 814-266-8745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD042800E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD042800E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: