Provider Demographics
NPI:1720465909
Name:SRIDHARAN, SRIVIDHYA (MD)
Entity Type:Individual
Prefix:MS
First Name:SRIVIDHYA
Middle Name:
Last Name:SRIDHARAN
Suffix:
Gender:F
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 1112
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26555-1112
Mailing Address - Country:US
Mailing Address - Phone:304-366-0700
Mailing Address - Fax:304-367-8766
Practice Address - Street 1:1322 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1436
Practice Address - Country:US
Practice Address - Phone:304-366-0700
Practice Address - Fax:304-367-8766
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV28397208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics