Provider Demographics
NPI:1801073226
Name:SRINIVASA, VIJAY KRISHNAKUMAR (MD)
Entity type:Individual
Prefix:
First Name:VIJAY
Middle Name:KRISHNAKUMAR
Last Name:SRINIVASA
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 1:5400 DUPONT CIRCLE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45154
Mailing Address - Country:US
Mailing Address - Phone:513-576-7700
Mailing Address - Fax:513-576-1020
Practice Address - Street 1:559 OLD STATE ROUTE 74
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45244-1518
Practice Address - Country:US
Practice Address - Phone:513-732-2820
Practice Address - Fax:513-732-2814
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.095716208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3106089Medicaid
OH3106089Medicaid