Provider Demographics
NPI:1184863938
Name:VAKA, SRINIVASA REDDY (MD)
Entity type:Individual
Prefix:DR
First Name:SRINIVASA
Middle Name:REDDY
Last Name:VAKA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:FAIRVIEW CLINICS-BASS LAKE
Mailing Address - Street 2:6320 WEDGWOOD RD N
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3647
Mailing Address - Country:US
Mailing Address - Phone:763-268-0400
Mailing Address - Fax:763-268-0405
Practice Address - Street 1:FAIRVIEW CLINICS-BASS LAKE
Practice Address - Street 2:6320 WEDGWOOD RD N
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-3647
Practice Address - Country:US
Practice Address - Phone:763-268-0400
Practice Address - Fax:763-268-0405
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE7137207R00000X, 208M00000X
MN65117207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR359682YJSBMedicare PIN