Provider Demographics
NPI:1801838222
Name:SIDDHARTHAN, RENUKA (MD)
Entity Type:Individual
Prefix:DR
First Name:RENUKA
Middle Name:
Last Name:SIDDHARTHAN
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 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1515 S OSPREY AVE STE A1
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2933
Practice Address - Country:US
Practice Address - Phone:941-917-7197
Practice Address - Fax:941-917-4016
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0051650207RG0300X
FLME 0051650207RH0002X
FLME51650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14Q7LOtherBCBS
FL064032800Medicaid
FL14Q7LOtherBCBS
09944Medicare ID - Type Unspecified