Provider Demographics
NPI:1346561669
Name:MEDIDI, SAROJA (MD)
Entity Type:Individual
Prefix:DR
First Name:SAROJA
Middle Name:
Last Name:MEDIDI
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 1:13110 ELK MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-7182
Mailing Address - Country:US
Mailing Address - Phone:813-349-7568
Mailing Address - Fax:813-349-7561
Practice Address - Street 1:14254 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:FL
Practice Address - Zip Code:33527-4414
Practice Address - Country:US
Practice Address - Phone:813-349-7700
Practice Address - Fax:813-349-7761
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009031800Medicaid