Provider Demographics
NPI:1891432910
Name:SREENIVASA RAO TADIKONDA
Entity Type:Organization
Organization Name:SREENIVASA RAO TADIKONDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SREENIVASA
Authorized Official - Middle Name:
Authorized Official - Last Name:TADIKONDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-547-0466
Mailing Address - Street 1:120 PALEO DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-8844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 EZELLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-7218
Practice Address - Country:US
Practice Address - Phone:318-251-3126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty