Provider Demographics
NPI:1740506229
Name:KANURI, SRIDEVI (MD)
Entity type:Individual
Prefix:DR
First Name:SRIDEVI
Middle Name:
Last Name:KANURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SRIDEVI
Other - Middle Name:
Other - Last Name:SOMPALLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:620 W EDISON RD
Mailing Address - Street 2:STE 110
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-2784
Mailing Address - Country:US
Mailing Address - Phone:574-258-1100
Mailing Address - Fax:574-258-1101
Practice Address - Street 1:620 W EDISON RD
Practice Address - Street 2:STE 110
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2784
Practice Address - Country:US
Practice Address - Phone:574-258-1100
Practice Address - Fax:574-258-1101
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361232422085R0202X
IN01069685A2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201021510Medicaid
INM400047403Medicare PIN