Provider Demographics
NPI:1710077136
Name:IYENGAR, SRIDHARA K S (MD)
Entity Type:Individual
Prefix:
First Name:SRIDHARA
Middle Name:K S
Last Name:IYENGAR
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 1:11100 WARNER AVE
Mailing Address - Street 2:# 320
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7511
Mailing Address - Country:US
Mailing Address - Phone:714-549-1294
Mailing Address - Fax:714-549-1296
Practice Address - Street 1:11100 WARNER AVE
Practice Address - Street 2:# 320
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7511
Practice Address - Country:US
Practice Address - Phone:714-549-1294
Practice Address - Fax:714-549-1296
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42391208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C423910Medicaid
E99321Medicare UPIN
CA00C423910Medicaid