Provider Demographics
NPI:1730286287
Name:SRINIVASAN, BHARANI G (MD)
Entity Type:Individual
Prefix:
First Name:BHARANI
Middle Name:G
Last Name:SRINIVASAN
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-285-4646
Mailing Address - Fax:
Practice Address - Street 1:3723 W 12600 S
Practice Address - Street 2:SUITE 270
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7295
Practice Address - Country:US
Practice Address - Phone:801-285-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49018131205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000059607Medicare PIN