Basic Information
| Provider Information | |||||||||
| NPI: | 1295920320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRISHNA | ||||||||
| FirstName: | VIVEK | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE STE 401 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228602 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 PATEWOOD DR STE B350 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296156337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644544500 | ||||||||
| FaxNumber: | 8644544505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0008X | 912984 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neuromuscular Medicine | 2084N0008X | 86829 | SC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neuromuscular Medicine | 2084N0400X | 42815 | AZ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 35.097878 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | P1777 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | 158833 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | 912984 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 912984 | 01 | CA | BOARD CERTIFICATION | OTHER |