Provider Demographics
NPI:1164740122
Name:VALLABHANENI, SRIDHAR (MD)
Entity Type:Individual
Prefix:
First Name:SRIDHAR
Middle Name:
Last Name:VALLABHANENI
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 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-649-3300
Mailing Address - Fax:414-649-7012
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PKWY STE 310
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-5643
Practice Address - Country:US
Practice Address - Phone:414-649-3300
Practice Address - Fax:414-649-7012
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074949A208100000X
IL036.137251208100000X
WI72134208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL12591405OtherCAQH
IL036137251Medicaid
WI100095270Medicaid
IN201297670Medicaid
IN141980005Medicare PIN