Provider Demographics
NPI:1952983488
Name:SRINIVAS, SHANMUKHA
Entity Type:Individual
Prefix:
First Name:SHANMUKHA
Middle Name:
Last Name:SRINIVAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 GILMAN DR DEPT 39
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-0039
Mailing Address - Country:US
Mailing Address - Phone:408-613-5371
Mailing Address - Fax:
Practice Address - Street 1:9500 GILMAN DR DEPT 39
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-0039
Practice Address - Country:US
Practice Address - Phone:408-613-5371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program