Provider Demographics
NPI:1922492107
Name:SRIDHAR, AVINASH MANICKAM (MD)
Entity Type:Individual
Prefix:DR
First Name:AVINASH
Middle Name:MANICKAM
Last Name:SRIDHAR
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 1:24 WHITE FAWN DR
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-4126
Mailing Address - Country:US
Mailing Address - Phone:508-733-3730
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0816
Practice Address - Country:US
Practice Address - Phone:434-243-7778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-02308207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPE-P4DQ1NAN8Medicaid