Provider Demographics
NPI:1609822550
Name:SRINIVASA, MANDYAM K (MD)
Entity Type:Individual
Prefix:MR
First Name:MANDYAM
Middle Name:K
Last Name:SRINIVASA
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 1:3307 CLIFTON AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-2064
Mailing Address - Country:US
Mailing Address - Phone:513-861-2490
Mailing Address - Fax:513-861-0148
Practice Address - Street 1:4777 E GALBRAITH RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2725
Practice Address - Country:US
Practice Address - Phone:513-686-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040662S207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0871641Medicaid
OHSR0633743Medicare ID - Type Unspecified