Provider Demographics
NPI:1174019996
Name:SRIMANTHULA, SOWMYA (MD)
Entity Type:Individual
Prefix:
First Name:SOWMYA
Middle Name:
Last Name:SRIMANTHULA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 AUBREYS LOOP
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-5054
Mailing Address - Country:US
Mailing Address - Phone:434-517-3879
Mailing Address - Fax:
Practice Address - Street 1:101 AUBREYS LOOP
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-5054
Practice Address - Country:US
Practice Address - Phone:434-517-3879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-04
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK33899390200000X
VA0101274781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program