Provider Demographics
NPI:1104030055
Name:IYENGAR, SRINIVAS (MD)
Entity Type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:
Last Name:IYENGAR
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 1:477 N EL CAMINO REAL
Mailing Address - Street 2:C-308
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1328
Mailing Address - Country:US
Mailing Address - Phone:760-942-9225
Mailing Address - Fax:760-942-9343
Practice Address - Street 1:477 N EL CAMINO REAL
Practice Address - Street 2:C-308
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1328
Practice Address - Country:US
Practice Address - Phone:760-942-9225
Practice Address - Fax:760-942-9343
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6444207W00000X
CAA105824207W00000X
FLME110731207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFH030ZMedicare PIN