Provider Demographics
NPI:1376562231
Name:SRIDHARAN, MARANDAPALLI R (MD)
Entity Type:Individual
Prefix:
First Name:MARANDAPALLI
Middle Name:R
Last Name:SRIDHARAN
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 1:1348 WALTON WAY
Mailing Address - Street 2:SUITE 5100
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-5104
Mailing Address - Country:US
Mailing Address - Phone:706-724-8611
Mailing Address - Fax:706-724-6202
Practice Address - Street 1:1348 WALTON WAY
Practice Address - Street 2:SUITE 5100
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-5104
Practice Address - Country:US
Practice Address - Phone:706-724-8611
Practice Address - Fax:706-724-6202
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026392207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA198050OtherBCBS
SCG26392Medicaid
SCG26392Medicaid
GA06BDJDDMedicare PIN