Provider Demographics
NPI:1639121627
Name:SRIDHAR, SHANTHY (MD)
Entity Type:Individual
Prefix:
First Name:SHANTHY
Middle Name:
Last Name:SRIDHAR
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 1:133 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3904
Mailing Address - Country:US
Mailing Address - Phone:617-421-5804
Mailing Address - Fax:617-421-8865
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-5804
Practice Address - Fax:617-421-8865
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0021220OtherNEIGHBORHOOD HEALTH
MA0123510Medicaid
MA207204OtherTUFTS
MAJ22961OtherBLUE CROSS
MAV015OtherHARVARD PILGRIM
MA0021220OtherNEIGHBORHOOD HEALTH
MAA32883Medicare PIN