Provider Demographics
NPI:1497953871
Name:BASAVANTHAPPA, SREENIVASA (MD)
Entity Type:Individual
Prefix:DR
First Name:SREENIVASA
Middle Name:
Last Name:BASAVANTHAPPA
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 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1784
Mailing Address - Country:US
Mailing Address - Phone:309-557-8666
Mailing Address - Fax:309-661-0545
Practice Address - Street 1:2501 E COLLEGE AVE STE B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2484
Practice Address - Country:US
Practice Address - Phone:309-557-8666
Practice Address - Fax:309-827-8027
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03-6163408207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110096239AMedicaid
MA003232702Medicare PIN
MA003232701Medicare PIN