Provider Demographics
NPI:1447241872
Name:ADDALA, SRINIVAS (MD)
Entity type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:
Last Name:ADDALA
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 1:9135 PISCATAWAY RD STE 210
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2542
Mailing Address - Country:US
Mailing Address - Phone:301-868-1380
Mailing Address - Fax:
Practice Address - Street 1:9135 PISCATAWAY RD STE 210
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2542
Practice Address - Country:US
Practice Address - Phone:301-868-1380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0047943207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD014960S66Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #