Basic Information
| Provider Information | |||||||||
| NPI: | 1619924636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRISHNAGOPALAN | ||||||||
| FirstName: | SREENANDH | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3288 MOANALUA RD | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968191469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084320000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3288 MOANALUA RD | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968191469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084320000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD10641 | HI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | MD10641 | HI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 25227323 | 05 | HI | MEDICAID | 25227321 | 05 | HI | MEDICAID | 25227322 | 05 | HI | MEDICAID |