Provider Demographics
NPI:1043201924
Name:SRIDHAR, KOLALA RAMAKRISHNASASTRY (MD)
Entity Type:Individual
Prefix:
First Name:KOLALA
Middle Name:RAMAKRISHNASASTRY
Last Name:SRIDHAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KOLALA
Other - Middle Name:R
Other - Last Name:SRIDHAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:105 WAWECUS ST
Mailing Address - Street 2:SUITE1
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2146
Mailing Address - Country:US
Mailing Address - Phone:860-859-9061
Mailing Address - Fax:860-889-6200
Practice Address - Street 1:2139 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-2336
Practice Address - Country:US
Practice Address - Phone:860-257-4131
Practice Address - Fax:860-257-4519
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA290596207RG0100X
CT023184207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2543540OtherAETNA HMO
CT4383009OtherAETNA PPO
CT010023184CT02OtherANTHEM BCBS CT
CT030206OtherHEALTHNET NE
CT611709OtherCONNECTICARE
CTNLS073OtherOXFORD
CT611709OtherCONNECTICARE
CT2543540OtherAETNA HMO
CTNLS073OtherOXFORD