Provider Demographics
NPI:1063482636
Name:SRIDHARA, BANGALORE S (MD)
Entity Type:Individual
Prefix:DR
First Name:BANGALORE
Middle Name:S
Last Name:SRIDHARA
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 1:20 GRAND STREET, 3RD FL
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-942-1001
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:12 LIBERTY SQUARE MALL
Practice Address - Street 2:
Practice Address - City:STONY POINT
Practice Address - State:NY
Practice Address - Zip Code:10980-2400
Practice Address - Country:US
Practice Address - Phone:845-942-1001
Practice Address - Fax:845-942-1431
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213781174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY961385OtherMVP/TACONIC IPA
NY193679OtherWELLCARE
NY213781OtherCONNECTICARE
NY213781OtherHIP
NY700608OtherUS FAMILY HEALTH PLAN
NY2386215OtherAETNA HMO
NYP00114326OtherRAILROAD MEDICARE
NY01943466Medicaid
NY58N891OtherEMPIRE BC STONY POINT
NYN67450OtherHEALTHNET
NY000000045698OtherGHI HMO
NY133693126OtherTAX ID #
NYP1979240OtherOXFORD
NY0181480OtherGHI PPO
NY58N892OtherEMPIRE BC WEST NYACK
NY7998110OtherAETNA PPO
NY58N892OtherEMPIRE BC WEST NYACK
NY01943466Medicaid
NYP00114326OtherRAILROAD MEDICARE