Provider Demographics
NPI:1710203104
Name:KOMAKULA, SIRISHA
Entity Type:Individual
Prefix:
First Name:SIRISHA
Middle Name:
Last Name:KOMAKULA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 N BROAD ST
Mailing Address - Street 2:APT #7
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-3349
Mailing Address - Country:US
Mailing Address - Phone:215-439-8851
Mailing Address - Fax:
Practice Address - Street 1:1922 N BROAD ST
Practice Address - Street 2:APT #7
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-3349
Practice Address - Country:US
Practice Address - Phone:215-439-8851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-11
Last Update Date:2010-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program