Provider Demographics
NPI:1881089472
Name:DANTULURI, SRINIVAS RAJU (DO)
Entity type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:RAJU
Last Name:DANTULURI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2FLOOR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:2840 SE 3RD CT STE 100
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-0480
Practice Address - Country:US
Practice Address - Phone:352-622-1777
Practice Address - Fax:352-622-1929
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15027207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJ7060OtherBCBS
FL100363400Medicaid
FLLL296OtherMEDICARE