Provider Demographics
NPI:1003024191
Name:PEDDI, SRINIVAS (MD)
Entity Type:Individual
Prefix:DR
First Name:SRINIVAS
Middle Name:
Last Name:PEDDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 EXECUTIVE PARK STE 155
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-4733
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:800-409-7005
Practice Address - Street 1:23929 MCBEAN PKWY
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-4466
Practice Address - Country:US
Practice Address - Phone:323-549-3030
Practice Address - Fax:323-549-3049
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110057822085R0202X
CAA1186252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003024191Medicaid
CA00A1186250OtherBLUE SHIELD OF CALIFORNIA
CA00A1186250OtherBLUE SHIELD OF CALIFORNIA
CAGG849ZMedicare PIN