Provider Demographics
NPI:1760478796
Name:SRINIVASAN, VISALAKSHI (MD)
Entity Type:Individual
Prefix:DR
First Name:VISALAKSHI
Middle Name:
Last Name:SRINIVASAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VISA
Other - Middle Name:
Other - Last Name:SRINIVASAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-7611
Mailing Address - Fax:
Practice Address - Street 1:3661 S BABCOCK ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-8903
Practice Address - Country:US
Practice Address - Phone:321-434-7611
Practice Address - Fax:321-727-3738
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084470207QG0300X
FLME94188207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6270YOtherFL MEDICARE
FL273765500Medicaid
FLU6270ZMedicare PIN