Provider Demographics
NPI:1821761263
Name:SRIDHARAN, SARUP S (MD)
Entity Type:Individual
Prefix:
First Name:SARUP
Middle Name:S
Last Name:SRIDHARAN
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 1:590 S WAKARA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1200
Mailing Address - Country:US
Mailing Address - Phone:801-536-3600
Mailing Address - Fax:
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-413-4844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12512523-1205207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery