Provider Demographics
NPI:1952336851
Name:SRIKUREJA, MAHATHEP MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:MAHATHEP
Middle Name:MATTHEW
Last Name:SRIKUREJA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:MAHATHEP
Other - Middle Name:MATTHEW
Other - Last Name:SRIKUREJA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 4259
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-4259
Mailing Address - Country:US
Mailing Address - Phone:562-407-2080
Mailing Address - Fax:562-407-2082
Practice Address - Street 1:4601 DALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9718
Practice Address - Country:US
Practice Address - Phone:209-735-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7504207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX75040Medicaid
CA20A7504Medicare ID - Type UnspecifiedMEDICARE NUMBER
CA00AX75040Medicaid