Provider Demographics
NPI:1134112592
Name:SRIDHAR, SRINIVASA (MD)
Entity Type:Individual
Prefix:MR
First Name:SRINIVASA
Middle Name:
Last Name:SRIDHAR
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 1:6451 N FEDERAL HWY STE 800
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1409
Mailing Address - Country:US
Mailing Address - Phone:800-586-5022
Mailing Address - Fax:866-889-7835
Practice Address - Street 1:301 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:386-231-3346
Practice Address - Fax:386-231-3357
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0027133207X00000X
MEMD26543207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL200036399OtherMEDICARE RAILROAD
FL64333ZMedicare PIN
FLD57645Medicare UPIN