1508977257 NPI number — KRISHNA KANTH R METTU MD

Table of content: KRISHNA KANTH R METTU MD (NPI 1508977257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508977257 NPI number — KRISHNA KANTH R METTU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
METTU
Provider First Name:
KRISHNA
Provider Middle Name:
KANTH R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508977257
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 104240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65110-4240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-635-5264
Provider Business Mailing Address Fax Number:
573-761-4351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1241 W STADIUM BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65109-6023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-635-5264
Provider Business Practice Location Address Fax Number:
573-761-4351
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  T2003012955 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084S0012X , with the licence number: 2009008002 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1508977257 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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