Healthcare Provider Details

I. General information

NPI: 1588014393
Provider Name (Legal Business Name): KRISHI VENKATA PEDDADA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 HARRISON BRIDGE RD
SIMPSONVILLE SC
29680-7132
US

IV. Provider business mailing address

PO BOX 11407
BIRMINGHAM AL
35246-8575
US

V. Phone/Fax

Practice location:
  • Phone: 864-654-6706
  • Fax:
Mailing address:
  • Phone: 864-359-1308
  • Fax: 239-496-3939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number87529
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number87529
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: