Provider Demographics
NPI:1831381433
Name:KOLIPAKA, SRINIVAS (MD)
Entity type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:
Last Name:KOLIPAKA
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 1:1503 N TIBBS RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2915
Mailing Address - Country:US
Mailing Address - Phone:706-270-5000
Mailing Address - Fax:706-270-5124
Practice Address - Street 1:191 LAMAR HALEY PKWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8019
Practice Address - Country:US
Practice Address - Phone:770-704-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE258902084P0800X
NC2016-009302084P0800X
TX390200000X
GA636772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1831381433Medicaid
SCNC2878Medicaid
NC1831381433Medicaid