Provider Demographics
NPI:1033173794
Name:SRIDHARAN, SUGANDHI (MD)
Entity Type:Individual
Prefix:
First Name:SUGANDHI
Middle Name:
Last Name:SRIDHARAN
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 1:1541 GULL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1639
Mailing Address - Country:US
Mailing Address - Phone:269-381-7380
Mailing Address - Fax:269-341-4562
Practice Address - Street 1:1541 GULL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1639
Practice Address - Country:US
Practice Address - Phone:269-381-7380
Practice Address - Fax:269-341-4562
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010846662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4778322Medicaid
MI4778322Medicaid