MEDICARE: DR. KRISHNA VIJAY PERSAUD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207K00000X	Allergy & Immunology Physician	205585	NY
2	207R00000X	Internal Medicine Physician	205585	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	102914AA	OTHER	NY	PREFERRED CARE ALLERGY
3	102914BJ	OTHER	NY	PREFERRED CARE IM
4	030000058	OTHER	NY	BLUE CHOICE ALLERGY
5	010000058	OTHER	NY	BLUE CHOICE IM

General Provider Information

NPI Number	:	1508829284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISHNA VIJAY PERSAUD MD

Provider Business Mailing Address
First Line	:	4418 E RIDGE RD
Second Line	:
City	:	WILLIAMSON
State	:	NY
Zip	:	14589-9375
Country	:	US
Telephone Number	:	315-589-4641
Fax Number	:	315-589-9585

Provider Business Practice Location Address
First Line	:	4418 E RIDGE RD
Second Line	:	WILLIAMSON MEDICAL PLLC
City	:	WILLIAMSON
State	:	NY
Zip	:	14589-9375
Country	:	US
Telephone Number	:	315-589-4641
Fax Number	:	315-589-9585

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2006
Last Update Date	:	07/05/2023

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