Provider Demographics
NPI:1912582263
Name:SRINIVASAN, SRIDEVI (RD, CHWC)
Entity Type:Individual
Prefix:
First Name:SRIDEVI
Middle Name:
Last Name:SRINIVASAN
Suffix:
Gender:F
Credentials:RD, CHWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5067 DURANGO CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-2317
Mailing Address - Country:US
Mailing Address - Phone:408-598-6064
Mailing Address - Fax:
Practice Address - Street 1:5067 DURANGO CT
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-2317
Practice Address - Country:US
Practice Address - Phone:408-598-6064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered