Provider Demographics
NPI:1023022894
Name:ALLA, SREENIVASA RAO (MD)
Entity Type:Individual
Prefix:DR
First Name:SREENIVASA
Middle Name:RAO
Last Name:ALLA
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 1:1801 SE HILLMOOR DR
Mailing Address - Street 2:SUITE-C 105
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7553
Mailing Address - Country:US
Mailing Address - Phone:772-337-9482
Mailing Address - Fax:772-398-8440
Practice Address - Street 1:1801 SE HILLMOOR DR
Practice Address - Street 2:SUITE-C 105
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7553
Practice Address - Country:US
Practice Address - Phone:772-337-9482
Practice Address - Fax:772-398-8440
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49438Medicare ID - Type Unspecified
FLH06234Medicare UPIN