Provider Demographics
NPI:1154313476
Name:KOSANAM, SRINATH REDDY (MD)
Entity Type:Individual
Prefix:
First Name:SRINATH
Middle Name:REDDY
Last Name:KOSANAM
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 1:10603 EMERALD CHASE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-5855
Mailing Address - Country:US
Mailing Address - Phone:863-424-8900
Mailing Address - Fax:863-424-8823
Practice Address - Street 1:106 POLO PARK EAST BLVD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-9407
Practice Address - Country:US
Practice Address - Phone:863-424-8900
Practice Address - Fax:863-424-8823
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78339207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2595853400Medicaid