Provider Demographics
NPI:1215266739
Name:SRIDHAR, PANDU RANGA (MD)
Entity type:Individual
Prefix:DR
First Name:PANDU
Middle Name:RANGA
Last Name:SRIDHAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36065 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5060
Mailing Address - Country:US
Mailing Address - Phone:254-553-5899
Mailing Address - Fax:254-287-7690
Practice Address - Street 1:36065 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:254-553-5899
Practice Address - Fax:254-287-7690
Is Sole Proprietor?:No
Enumeration Date:2009-12-11
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067444A2080S0010X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200971930Medicaid