Provider Demographics
NPI:1013536200
Name:SRIDHAR, SUPRAJA (MD)
Entity Type:Individual
Prefix:
First Name:SUPRAJA
Middle Name:
Last Name:SRIDHAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE # M8-419
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-444-5633
Mailing Address - Fax:216-688-2727
Practice Address - Street 1:9500 EUCLID AVE # M8-419
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-2865
Practice Address - Country:US
Practice Address - Phone:216-444-5633
Practice Address - Fax:216-688-2727
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA323222207R00000X
OH35.148667208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist