Provider Demographics
NPI:1003122003
Name:SRA, MINI
Entity Type:Individual
Prefix:
First Name:MINI
Middle Name:
Last Name:SRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MANDEEP
Other - Middle Name:
Other - Last Name:SRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MBBS
Mailing Address - Street 1:5215 HOLY CROSS PKWY
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1469
Mailing Address - Country:US
Mailing Address - Phone:574-335-2521
Mailing Address - Fax:574-335-2262
Practice Address - Street 1:5215 HOLY CROSS PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1469
Practice Address - Country:US
Practice Address - Phone:574-335-2521
Practice Address - Fax:574-335-2262
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072359A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine