Provider Demographics
NPI:1184691305
Name:TADAKAMALLA, SRINATH (MD)
Entity type:Individual
Prefix:DR
First Name:SRINATH
Middle Name:
Last Name:TADAKAMALLA
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:PO BOX 23085
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66283-3085
Mailing Address - Country:US
Mailing Address - Phone:816-813-7027
Mailing Address - Fax:913-674-5563
Practice Address - Street 1:3001 E ELM ST
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701
Practice Address - Country:US
Practice Address - Phone:816-813-7027
Practice Address - Fax:913-674-5563
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005025981207Q00000X, 208M00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207472903Medicaid
MO207472903Medicaid
145F215FMedicare ID - Type Unspecified
MOBT7401728OtherDEA
I02298Medicare UPIN
P00284622Medicare ID - Type UnspecifiedRR MCR