Basic Information
| Provider Information | |||||||||
| NPI: | 1083756852 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIRUMALA | ||||||||
| FirstName: | KRISHNA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3599 UNIVERSITY BLVD S | ||||||||
| Address2: | BUILDING 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043995550 | ||||||||
| FaxNumber: | 9043464334 | ||||||||
| Practice Location | |||||||||
| Address1: | 3599 UNIVERSITY BLVD S | ||||||||
| Address2: | BUILDING 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043995550 | ||||||||
| FaxNumber: | 9043464334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME97416 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 277749500 | 05 | FL | MEDICAID | P00434974 | 01 | GA | RAILROAD MEDICARE | OTHER | 519719105A | 05 | GA | MEDICAID | 92886 | 01 | FL | BCBS | OTHER |