Provider Demographics
NPI: | 1184863938 |
---|---|
Name: | VAKA, SRINIVASA REDDY (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | SRINIVASA |
Middle Name: | REDDY |
Last Name: | VAKA |
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: | FAIRVIEW CLINICS-BASS LAKE |
Mailing Address - Street 2: | 6320 WEDGWOOD RD N |
Mailing Address - City: | MAPLE GROVE |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55311-3647 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 763-268-0400 |
Mailing Address - Fax: | 763-268-0405 |
Practice Address - Street 1: | FAIRVIEW CLINICS-BASS LAKE |
Practice Address - Street 2: | 6320 WEDGWOOD RD N |
Practice Address - City: | MAPLE GROVE |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55311-3647 |
Practice Address - Country: | US |
Practice Address - Phone: | 763-268-0400 |
Practice Address - Fax: | 763-268-0405 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2009-02-17 |
Last Update Date: | 2019-09-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AR | E7137 | 207R00000X, 208M00000X |
MN | 65117 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AR | 359682YJSB | Medicare PIN |