Provider Demographics
NPI:1922083120
Name:TUMMALA, SRINIVAS (MD)
Entity Type:Individual
Prefix:DR
First Name:SRINIVAS
Middle Name:
Last Name:TUMMALA
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 1:5846 S FLAMINGO RD STE 315
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33330-3237
Mailing Address - Country:US
Mailing Address - Phone:954-852-3831
Mailing Address - Fax:
Practice Address - Street 1:3 SW 129TH AVE STE 101-102
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1775
Practice Address - Country:US
Practice Address - Phone:954-852-3831
Practice Address - Fax:954-852-3832
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00775962085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000902228BMedicaid
GA000902228BMedicaid
GA30BDKGTMedicare ID - Type Unspecified
GA000902228BMedicaid
AP470ZMedicare PIN