Provider Demographics
NPI:1982834438
Name:CLARK, SIREESHA ACHANTI (MD)
Entity Type:Individual
Prefix:
First Name:SIREESHA
Middle Name:ACHANTI
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SIREESHA
Other - Middle Name:
Other - Last Name:ACHANTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:347 W MILLTOWN RD STE B
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-7216
Mailing Address - Country:US
Mailing Address - Phone:330-345-1540
Mailing Address - Fax:330-345-1541
Practice Address - Street 1:347 W MILLTOWN RD STE B
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-7216
Practice Address - Country:US
Practice Address - Phone:330-345-1540
Practice Address - Fax:330-345-1541
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.121480207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000958305OtherANTHEM BLUE CROSS & BLUE SHIELD
OHH219813Medicare PIN