Provider Demographics
NPI:1447321559
Name:SRINIVASAN, LAVANYA JANARDAN (RD)
Entity type:Individual
Prefix:MRS
First Name:LAVANYA
Middle Name:JANARDAN
Last Name:SRINIVASAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4680 REAGAN ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-7466
Mailing Address - Country:US
Mailing Address - Phone:409-899-4428
Mailing Address - Fax:
Practice Address - Street 1:3787 DOCTORS DR
Practice Address - Street 2:SUITE #107
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-5514
Practice Address - Country:US
Practice Address - Phone:409-983-2039
Practice Address - Fax:409-983-4209
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04993133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00808FMedicare ID - Type UnspecifiedREGISTERED DIETITIAN