Provider Demographics
NPI:1477695351
Name:SRIDHARA, SRIVIDYA (MD)
Entity type:Individual
Prefix:DR
First Name:SRIVIDYA
Middle Name:
Last Name:SRIDHARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 GEORGIAN CT
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8652
Mailing Address - Country:US
Mailing Address - Phone:408-431-0256
Mailing Address - Fax:
Practice Address - Street 1:623 W FM 544
Practice Address - Street 2:STE 104
Practice Address - City:MURPHY
Practice Address - State:TX
Practice Address - Zip Code:75094-4577
Practice Address - Country:US
Practice Address - Phone:972-521-3366
Practice Address - Fax:972-422-5656
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4113207RA0201X
CAA107039207K00000X
MN53480207K00000X
OK25109390200000X
MN104968207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN030000327Medicare PIN