Provider Demographics
NPI:1497856041
Name:TIKKO, SIRISHA R (MD)
Entity Type:Individual
Prefix:
First Name:SIRISHA
Middle Name:R
Last Name:TIKKO
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 1:161 MADISON AVE
Mailing Address - Street 2:SUITE 10E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:212-889-5914
Mailing Address - Fax:212-889-1963
Practice Address - Street 1:161 MADISON AVE
Practice Address - Street 2:SUITE 10E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-889-5914
Practice Address - Fax:212-889-1963
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140979208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01025896Medicaid
NY01025896Medicaid
12D102Medicare ID - Type Unspecified