Provider Demographics
NPI:1891946646
Name:MADDIPATLA, SREERAM (MD)
Entity Type:Individual
Prefix:
First Name:SREERAM
Middle Name:
Last Name:MADDIPATLA
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 1:9430 TURKEY LAKE RD STE 218
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8015
Mailing Address - Country:US
Mailing Address - Phone:407-648-3800
Mailing Address - Fax:407-425-5203
Practice Address - Street 1:9430 TURKEY LAKE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8015
Practice Address - Country:US
Practice Address - Phone:407-648-3800
Practice Address - Fax:407-425-5203
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME102364207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001904900Medicaid
FLME102364OtherMEDICAL LICENSE
FLDA196ZMedicare PIN