Provider Demographics
NPI:1881889970
Name:TADIKONDA, SREENIVASA RAO (MD)
Entity type:Individual
Prefix:
First Name:SREENIVASA
Middle Name:RAO
Last Name:TADIKONDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TADIKONDA
Other - Middle Name:SRINIVASA
Other - Last Name:RAO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:120 PALEO DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-8844
Mailing Address - Country:US
Mailing Address - Phone:318-651-7410
Mailing Address - Fax:
Practice Address - Street 1:120 PALEO DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-8844
Practice Address - Country:US
Practice Address - Phone:318-651-7410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD201751207Q00000X
LAMD.201751208M00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1071340Medicaid
LA2111752Medicaid
LA4P665DF59Medicare PIN
LA4K973CY61Medicare PIN
LA4K973DJ97Medicare PIN
LA4K973DN95Medicare PIN
LA4K973DF59Medicare PIN
LAP00602779Medicare PIN