Provider Demographics
NPI:1649379785
Name:DHATREECHARA N, SRINIVASAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SRINIVASAN
Middle Name:
Last Name:DHATREECHARA N
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SRI
Other - Middle Name:
Other - Last Name:DHATREE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:420 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:DOWAGIAC
Mailing Address - State:MI
Mailing Address - Zip Code:49047-1943
Mailing Address - Country:US
Mailing Address - Phone:269-783-3017
Mailing Address - Fax:
Practice Address - Street 1:420 W HIGH ST
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-1943
Practice Address - Country:US
Practice Address - Phone:269-783-3017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073450207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4212136Medicaid
MI25-30174OtherPHP/IBA
MISD073450OtherBCBS
MIP106615OtherBCN
MISD073450OtherBCBS
MI25-30174OtherPHP/IBA