Provider Demographics
NPI:1780958058
Name:CONJEEVARAM, SRINIVASULU (MD)
Entity type:Individual
Prefix:DR
First Name:SRINIVASULU
Middle Name:
Last Name:CONJEEVARAM
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 1:11 WINTHROP RD
Mailing Address - Street 2:APT 2A
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1656
Mailing Address - Country:US
Mailing Address - Phone:860-415-3622
Mailing Address - Fax:860-540-1226
Practice Address - Street 1:100 LINWOOD AVE STE 2A
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1138
Practice Address - Country:US
Practice Address - Phone:860-415-3622
Practice Address - Fax:860-974-0884
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53644207R00000X, 208D00000X, 207Q00000X, 208D00000X
MI4301086842208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT053644OtherSTATE MEDICAL LICENSE
CT053644OtherSTATE MEDICAL LICENSE
NYP68047OtherLIMITED PERMIT