Provider Demographics
NPI:1912909003
Name:THOTA, SRIYUTA (OD)
Entity Type:Individual
Prefix:DR
First Name:SRIYUTA
Middle Name:
Last Name:THOTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 HOMELAND DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-2145
Mailing Address - Country:US
Mailing Address - Phone:281-989-3155
Mailing Address - Fax:
Practice Address - Street 1:4400 N MIDLAND DR
Practice Address - Street 2:SUITE 404
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-3385
Practice Address - Country:US
Practice Address - Phone:432-695-6259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6263TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166650505Medicaid
TXTXB159941Medicare PIN
TX166650503Medicaid
TXU81425Medicare UPIN
TX00E63GMedicare UPIN
TX8C1620Medicare ID - Type Unspecified
TXTXB159940Medicare PIN
TX166650504Medicaid
TX166650501Medicaid
TXTXB159943Medicare PIN
TX1124091-04Medicaid