Provider Demographics
NPI:1275630980
Name:BIRADAVOLU, LAKSHMI BHASKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:LAKSHMI
Middle Name:BHASKAR
Last Name:BIRADAVOLU
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 1:722 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-2435
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:200 MADISON AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3218
Practice Address - Country:US
Practice Address - Phone:607-732-1310
Practice Address - Fax:607-733-0940
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194995208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01648219Medicaid
NYJ400169256Medicare PIN
NY01648219Medicaid