Provider Demographics
NPI:1760740195
Name:ELLICKAL, SRIDEVI (MD)
Entity Type:Individual
Prefix:
First Name:SRIDEVI
Middle Name:
Last Name:ELLICKAL
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 1:1200 PLEASANT STREET
Mailing Address - Street 2:SOUTH 2 ROOM 236
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50301
Mailing Address - Country:US
Mailing Address - Phone:515-241-6228
Mailing Address - Fax:515-241-8685
Practice Address - Street 1:1 BAYLOR PLZ
Practice Address - Street 2:DEPT OF PEDIATRICS, BCM 320
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3411
Practice Address - Country:US
Practice Address - Phone:832-824-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-45510208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics