MEDICARE: ACHYUTH SRIRAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	A178841	CA

General Provider Information

NPI Number	:	1093274805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ACHYUTH SRIRAM MD

Provider Business Mailing Address
First Line	:	1626 MALCOLM AVE APT 301
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-7830
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	757 WESTWOOD PLZ
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-5641
Country	:	US
Telephone Number	:	310-825-2631
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2019
Last Update Date	:	07/07/2023

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