Provider Demographics
NPI:1770686974
Name:SRIDHARA SASTRY MD PA
Entity type:Organization
Organization Name:SRIDHARA SASTRY MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SRIDHARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SASTRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-855-7884
Mailing Address - Street 1:PO BOX 21727
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-1727
Mailing Address - Country:US
Mailing Address - Phone:727-823-2188
Mailing Address - Fax:727-823-9502
Practice Address - Street 1:5003 E LONGBOAT BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4229
Practice Address - Country:US
Practice Address - Phone:813-855-7884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045861900Medicaid
FL045861900Medicaid
FL03864Medicare ID - Type Unspecified
FLFV211AMedicare PIN