Provider Demographics
NPI:1558335646
Name:BONTHU, SRINIVAS (MD)
Entity Type:Individual
Prefix:MR
First Name:SRINIVAS
Middle Name:
Last Name:BONTHU
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-0130
Mailing Address - Country:US
Mailing Address - Phone:518-786-1291
Mailing Address - Fax:518-786-1293
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4246
Practice Address - Country:US
Practice Address - Phone:518-786-1291
Practice Address - Fax:518-786-1293
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1971702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02677521Medicaid
NYP00313794Medicare PIN
G21437Medicare UPIN
NYP00313794Medicare PIN