Healthcare Provider Details

I. General information

NPI: 1467681759
Provider Name (Legal Business Name): SRIDIVYA I RAMINENI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SRIDIVYA I VEERAVALLI M.D.

II. Dates (important events)

Enumeration Date: 07/07/2009
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W CHANDLER BLVD
CHANDLER AZ
85224
US

IV. Provider business mailing address

25500 N NORTERRA DR
PHOENIX AZ
85085
US

V. Phone/Fax

Practice location:
  • Phone: 480-821-7565
  • Fax: 480-821-4303
Mailing address:
  • Phone: 623-277-1000
  • Fax: 866-837-6575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301094375
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: