Provider Demographics
NPI:1770576084
Name:NIRGUDKAR, SRIRAM D (MD)
Entity type:Individual
Prefix:DR
First Name:SRIRAM
Middle Name:D
Last Name:NIRGUDKAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-648-6667
Mailing Address - Fax:607-648-4141
Practice Address - Street 1:91 CHENANGO BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-1293
Practice Address - Country:US
Practice Address - Phone:607-648-6667
Practice Address - Fax:607-648-4141
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY115980208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00435507Medicaid
NY00435507Medicaid
NY56709QMedicare PIN