Provider Demographics
NPI:1275819526
Name:DATLA, SIREESHA (MD)
Entity Type:Individual
Prefix:
First Name:SIREESHA
Middle Name:
Last Name:DATLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SIREESHA
Other - Middle Name:
Other - Last Name:DATLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:1201 5TH AVE N STE 505
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1455
Practice Address - Country:US
Practice Address - Phone:727-821-0017
Practice Address - Fax:727-822-7473
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263027207R00000X, 390200000X
FLME161713207RH0000X, 207RX0202X
AZ57785207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118166200Medicaid