Provider Demographics
NPI:1134112592
Name:SRIDHAR, SRINIVASA (MD)
Entity type:Individual
Prefix:MR
First Name:SRINIVASA
Middle Name:
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 1:740 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3282
Mailing Address - Country:US
Mailing Address - Phone:386-734-9122
Mailing Address - Fax:
Practice Address - Street 1:740 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3282
Practice Address - Country:US
Practice Address - Phone:386-734-9122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0027133207X00000X
MEMD26543207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL200036399OtherMEDICARE RAILROAD
FL64333ZMedicare PIN
FLD57645Medicare UPIN