Provider Demographics
NPI:1518988823
Name:TADISETTI, SIVA PRASANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:SIVA PRASANNA
Middle Name:
Last Name:TADISETTI
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 1:2995 DREW ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7496
Mailing Address - Fax:
Practice Address - Street 1:2615 WINDGUARD CIR
Practice Address - Street 2:STE 102
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-7353
Practice Address - Country:US
Practice Address - Phone:813-333-3331
Practice Address - Fax:813-466-7482
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94439208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77464773OtherAETNA
FL274142300Medicaid
FL31547OtherBLUE CROSS BLUE SHIELD