Provider Demographics
NPI:1851382709
Name:SRESTHADATTA, PAUL (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:SRESTHADATTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9431 PINE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-6505
Mailing Address - Country:US
Mailing Address - Phone:614-420-6224
Mailing Address - Fax:
Practice Address - Street 1:9431 PINE CREEK DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-6505
Practice Address - Country:US
Practice Address - Phone:614-420-6224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2011-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007180208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2304885Medicaid
OHH58280Medicare UPIN
OHSR4073162Medicare PIN