Provider Demographics
NPI:1679885388
Name:GATLA, SRINIVAS RAO (MD)
Entity Type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:RAO
Last Name:GATLA
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 1:36123 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:734-464-0887
Mailing Address - Fax:734-402-0254
Practice Address - Street 1:36123 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1216
Practice Address - Country:US
Practice Address - Phone:734-464-0887
Practice Address - Fax:734-402-0254
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-10
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097208207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine