Provider Demographics
NPI:1902898257
Name:MURALIDHASAN, SRIRENGAM (MD)
Entity type:Individual
Prefix:
First Name:SRIRENGAM
Middle Name:
Last Name:MURALIDHASAN
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 1:1605 EL PASEO RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-6010
Mailing Address - Country:US
Mailing Address - Phone:575-523-5400
Mailing Address - Fax:575-523-5401
Practice Address - Street 1:1605 EL PASEO RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-6010
Practice Address - Country:US
Practice Address - Phone:575-523-5400
Practice Address - Fax:575-523-5401
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98-125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP00212854OtherRR MEDICARE
NM41326857Medicaid
NM344510401Medicare PIN
G85230Medicare UPIN