Provider Demographics
NPI:1710265467
Name:TANIKELLA, SANTISREE (MD)
Entity Type:Individual
Prefix:
First Name:SANTISREE
Middle Name:
Last Name:TANIKELLA
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:4203 HOSPITAL RD.
Practice Address - Street 2:
Practice Address - City:COAL TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:17866-6041
Practice Address - Country:US
Practice Address - Phone:570-648-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X390200000X
PAMD460347208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program