Provider Demographics
NPI:1568520187
Name:GONNALAGADDA, SREERAM (MD)
Entity Type:Individual
Prefix:
First Name:SREERAM
Middle Name:
Last Name:GONNALAGADDA
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 1:5140 LEGENDARY DR STE 100A
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-9042
Mailing Address - Country:US
Mailing Address - Phone:972-867-9507
Mailing Address - Fax:972-578-7705
Practice Address - Street 1:5140 LEGENDARY DR STE 100A
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-9042
Practice Address - Country:US
Practice Address - Phone:972-867-9507
Practice Address - Fax:972-578-7705
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2446207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG37620040Medicare PIN
MIG37620040Medicare PIN