Provider Demographics
NPI: | 1760643811 |
---|---|
Name: | CHINTA, SRI SANKAR (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | SRI SANKAR |
Middle Name: | |
Last Name: | CHINTA |
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: | 9000 W WISCONSIN AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | MILWAUKEE |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 53226-4874 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 414-266-2625 |
Mailing Address - Fax: | 414-266-2635 |
Practice Address - Street 1: | 9000 W WISCONSIN AVE |
Practice Address - Street 2: | |
Practice Address - City: | MILWAUKEE |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53226 |
Practice Address - Country: | US |
Practice Address - Phone: | 414-266-2625 |
Practice Address - Fax: | 414-266-2635 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-06-21 |
Last Update Date: | 2018-07-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 2010020728 | 208000000X, 2080P0204X |
WI | 69400 | 2080P0204X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2080P0204X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 1760643811 | Medicaid | |
IL | ENROLLED | Medicaid | |
WI | 1760643811 | Medicaid |