Provider Demographics
NPI:1164700605
Name:KOMIRISETTY, SRINIVASA RAO
Entity Type:Individual
Prefix:
First Name:SRINIVASA RAO
Middle Name:
Last Name:KOMIRISETTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10010 BELLE RIVE BLVD APT 510
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9519
Mailing Address - Country:US
Mailing Address - Phone:409-782-2402
Mailing Address - Fax:
Practice Address - Street 1:10010 BELLE RIVE BLVD APT 510
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9519
Practice Address - Country:US
Practice Address - Phone:409-782-2402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055526-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY055526-1Medicaid