Provider Demographics
NPI:1629163241
Name:HARIKRISHNA, SODAGAM N
Entity Type:Individual
Prefix:
First Name:SODAGAM
Middle Name:N
Last Name:HARIKRISHNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 298
Mailing Address - Street 2:
Mailing Address - City:SNEADS
Mailing Address - State:FL
Mailing Address - Zip Code:32460
Mailing Address - Country:US
Mailing Address - Phone:850-415-2583
Mailing Address - Fax:
Practice Address - Street 1:20454 NE FINLAY AVENUE
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424
Practice Address - Country:US
Practice Address - Phone:850-415-2583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND1305133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8073Medicare ID - Type UnspecifiedMEDICARE PART B PROV #