Provider Demographics
NPI:1508091489
Name:SIRIVOL, MAMATHA (MD)
Entity type:Individual
Prefix:
First Name:MAMATHA
Middle Name:
Last Name:SIRIVOL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:43 WHITING HILL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1006
Mailing Address - Country:US
Mailing Address - Phone:207-973-5035
Mailing Address - Fax:207-973-5042
Practice Address - Street 1:350 N COX ST STE 28
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5514
Practice Address - Country:US
Practice Address - Phone:336-629-6500
Practice Address - Fax:336-629-9500
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2024-06-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI57322-20207Q00000X
MEMD21574207Q00000X
NC2024-00275207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine