Provider Demographics
NPI:1346416559
Name:KETHARAJU, SRINIVAS (MD)
Entity Type:Individual
Prefix:DR
First Name:SRINIVAS
Middle Name:
Last Name:KETHARAJU
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 1:3 LYON PL
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2590
Mailing Address - Country:US
Mailing Address - Phone:315-713-6700
Mailing Address - Fax:866-816-0815
Practice Address - Street 1:3 LYON PL
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2590
Practice Address - Country:US
Practice Address - Phone:315-713-6700
Practice Address - Fax:866-816-0815
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43564207V00000X
NY280458207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04262126Medicaid