Provider Demographics
NPI:1083874317
Name:GADDAM, SRIKANTH (MD)
Entity Type:Individual
Prefix:
First Name:SRIKANTH
Middle Name:
Last Name:GADDAM
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 1:4400 LONG PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1892
Mailing Address - Country:US
Mailing Address - Phone:469-322-7481
Mailing Address - Fax:469-322-7807
Practice Address - Street 1:4400 LONG PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1892
Practice Address - Country:US
Practice Address - Phone:469-322-7481
Practice Address - Fax:469-322-7807
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR0399207Q00000X
TN47564207Q00000X, 208M00000X
VA0101250346208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1083874317Medicaid
TNQ002146Medicaid
VAV V3097AMedicare PIN
TN103I089641Medicare PIN
VAV V3097BMedicare PIN
VA1083874317Medicaid