Provider Demographics
NPI:1750598363
Name:SRINIVASAN, SRIDHAR (MD)
Entity type:Individual
Prefix:DR
First Name:SRIDHAR
Middle Name:
Last Name:SRINIVASAN
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 45278
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32232-5278
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-393-7603
Practice Address - Street 1:14546 OLD SAINT AUGUSTINE RD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5468
Practice Address - Country:US
Practice Address - Phone:904-202-7300
Practice Address - Fax:904-202-7377
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062292207RH0003X
MI4301085324207RH0003X
FLME99519207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology