Provider Demographics
NPI:1417985854
Name:KANUMURU, SRILATHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SRILATHA
Middle Name:
Last Name:KANUMURU
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 1:5354 AMBROSIA DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6862
Mailing Address - Country:US
Mailing Address - Phone:410-719-0020
Mailing Address - Fax:410-744-6755
Practice Address - Street 1:11085 LITTLE PATUXENT PKWY
Practice Address - Street 2:SUITE L001
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2983
Practice Address - Country:US
Practice Address - Phone:410-884-4939
Practice Address - Fax:410-884-4991
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064539207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0000Medicaid
PA4001Medicaid
PA4001Medicaid