Provider Demographics
NPI:1154397545
Name:SULLIVAN, SRIDEVI (MD)
Entity type:Individual
Prefix:DR
First Name:SRIDEVI
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SRIDEVI
Other - Middle Name:
Other - Last Name:REDDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4302
Practice Address - Country:US
Practice Address - Phone:617-661-5585
Practice Address - Fax:617-661-5107
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36099862207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H34058Medicare UPIN
IL205542Medicare ID - Type Unspecified
ILK01692Medicare ID - Type Unspecified