Provider Demographics
NPI:1225189392
Name:SRINIVASAN, PADMAVATHI N (MD)
Entity Type:Individual
Prefix:
First Name:PADMAVATHI
Middle Name:N
Last Name:SRINIVASAN
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 1:1845 PRECINCT LINE RD
Mailing Address - Street 2:STE 209
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3109
Mailing Address - Country:US
Mailing Address - Phone:817-336-4638
Mailing Address - Fax:817-336-7637
Practice Address - Street 1:1845 PRECINCT LINE RD STE 209
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3109
Practice Address - Country:US
Practice Address - Phone:817-336-4638
Practice Address - Fax:817-336-1331
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM37462085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00463016OtherMEDICARE RR
TX185923303Medicaid
TX8J6276Medicare PIN
TX185923303Medicaid