Provider Demographics
NPI:1164498234
Name:PAKNIKAR, SREEDHAR (MD)
Entity Type:Individual
Prefix:
First Name:SREEDHAR
Middle Name:
Last Name:PAKNIKAR
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 1:1321 STONE ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3520
Mailing Address - Country:US
Mailing Address - Phone:810-984-1000
Mailing Address - Fax:810-984-3138
Practice Address - Street 1:1321 STONE ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3520
Practice Address - Country:US
Practice Address - Phone:810-984-1000
Practice Address - Fax:810-984-3138
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040155208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164498234Medicaid
B43825Medicare UPIN