Provider Demographics
NPI:1720040454
Name:DUTT, SRINIVAS (MD)
Entity Type:Individual
Prefix:MR
First Name:SRINIVAS
Middle Name:
Last Name:DUTT
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 1:12214 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-2631
Mailing Address - Country:US
Mailing Address - Phone:352-596-9995
Mailing Address - Fax:352-596-9791
Practice Address - Street 1:12214 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-2631
Practice Address - Country:US
Practice Address - Phone:352-596-9995
Practice Address - Fax:352-596-9791
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65052207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6022110001Medicare NSC
FL29558ZMedicare ID - Type Unspecified
FLF23755Medicare UPIN