Provider Demographics
NPI:1225084155
Name:SRINIVASAN, PATTANAM DORAI (MD)
Entity Type:Individual
Prefix:
First Name:PATTANAM
Middle Name:DORAI
Last Name:SRINIVASAN
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 1:110 N MUIRFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8182
Mailing Address - Country:US
Mailing Address - Phone:765-319-3522
Mailing Address - Fax:765-319-3522
Practice Address - Street 1:1831 N BELCHER RD STE E1
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-1442
Practice Address - Country:US
Practice Address - Phone:765-319-3522
Practice Address - Fax:765-450-6161
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056628A207LP2900X, 208VP0014X
FLME124951208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200434770Medicaid
IN200434770Medicaid
IN232500AMedicare ID - Type Unspecified
INH81671Medicare UPIN