Provider Demographics
NPI:1366428765
Name:MURTHY, SREENIVASA L (MD)
Entity type:Individual
Prefix:
First Name:SREENIVASA
Middle Name:L
Last Name:MURTHY
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 1:2034 BENEDICT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-4404
Mailing Address - Country:US
Mailing Address - Phone:718-822-6262
Mailing Address - Fax:718-822-2088
Practice Address - Street 1:2034 BENEDICT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4404
Practice Address - Country:US
Practice Address - Phone:718-822-6262
Practice Address - Fax:718-822-2088
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135741208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00363864Medicaid
C10066Medicare UPIN
NY45A312Medicare PIN