Provider Demographics
NPI:1871245399
Name:SRINIVAS, PRAVINA (PHD, MLS)
Entity Type:Individual
Prefix:
First Name:PRAVINA
Middle Name:
Last Name:SRINIVAS
Suffix:
Gender:F
Credentials:PHD, MLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 MELROSE CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7120
Mailing Address - Country:US
Mailing Address - Phone:817-680-8061
Mailing Address - Fax:
Practice Address - Street 1:614 MELROSE CT
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7120
Practice Address - Country:US
Practice Address - Phone:817-680-8061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory