Provider Demographics
NPI:1891704565
Name:JATLA, SRIDHAR (MD)
Entity Type:Individual
Prefix:
First Name:SRIDHAR
Middle Name:
Last Name:JATLA
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 1:6983 HILLSDALE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2054
Mailing Address - Country:US
Mailing Address - Phone:317-849-8350
Mailing Address - Fax:317-576-6311
Practice Address - Street 1:2330 S DIXON RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6411
Practice Address - Country:US
Practice Address - Phone:765-455-8822
Practice Address - Fax:765-865-3935
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063214A2084P0800X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200903530Medicaid
IN200903530Medicaid