Healthcare Provider Details

I. General information

NPI: 1174966253
Provider Name (Legal Business Name): KRISHNA KISHORE KILARU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 N POWELTON AVE
PHILADELPHIA PA
19104-2640
US

IV. Provider business mailing address

3910 N POWELTON AVE
PHILADELPHIA PA
19104-2640
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-8747
  • Fax: 215-243-3258
Mailing address:
  • Phone: 215-662-8747
  • Fax: 215-243-3258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberMD471880
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: