Provider Demographics
NPI:1477694537
Name:MADDINENI, SRIDEVI (MD)
Entity Type:Individual
Prefix:DR
First Name:SRIDEVI
Middle Name:
Last Name:MADDINENI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:SRIDEVI
Other - Middle Name:MADDINENI
Other - Last Name:VISA HARAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:73 THOMPSON POYNTER ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741
Mailing Address - Country:US
Mailing Address - Phone:606-878-6899
Mailing Address - Fax:606-862-4899
Practice Address - Street 1:73 THOMPSON POYNTER ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741
Practice Address - Country:US
Practice Address - Phone:606-878-6899
Practice Address - Fax:606-862-4899
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40196208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000526210OtherANTHEM BLUE CROSS
KY7100036690Medicaid
KY7100036690Medicaid
KY0948102Medicare PIN