Provider Demographics
NPI:1477695351
Name:SRIDHARA, SRIVIDYA (MD)
Entity Type:Individual
Prefix:DR
First Name:SRIVIDYA
Middle Name:
Last Name:SRIDHARA
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 1:8124 BENT TREE SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-6915
Mailing Address - Country:US
Mailing Address - Phone:408-490-1416
Mailing Address - Fax:
Practice Address - Street 1:623 W FM 544
Practice Address - Street 2:STE 104
Practice Address - City:MURPHY
Practice Address - State:TX
Practice Address - Zip Code:75094-4577
Practice Address - Country:US
Practice Address - Phone:972-521-3366
Practice Address - Fax:972-422-5656
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104968207K00000X
CAA107039207K00000X
TXP4113207RA0201X
OK25109390200000X
MN53480207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN030000327Medicare PIN