Provider Demographics
NPI:1851324552
Name:SRINIVAS, DASARATHY (MD)
Entity Type:Individual
Prefix:
First Name:DASARATHY
Middle Name:
Last Name:SRINIVAS
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 1:1051 GAUSE BLVD STE 370
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2998
Mailing Address - Country:US
Mailing Address - Phone:985-280-4600
Mailing Address - Fax:985-280-4642
Practice Address - Street 1:1051 GAUSE BLVD STE 370
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2998
Practice Address - Country:US
Practice Address - Phone:985-280-4600
Practice Address - Fax:985-280-4642
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05745R207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1323641Medicaid
LA1323641Medicaid
LAB89896Medicare UPIN