Healthcare Provider Details

I. General information

NPI: 1306920640
Provider Name (Legal Business Name): SRIDHAR PRATHIKANTI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BON AIR RD PES
GREENBRAE CA
94904-1702
US

IV. Provider business mailing address

250 BON AIR RD PES
GREENBRAE CA
94904-1702
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-6666
  • Fax:
Mailing address:
  • Phone: 415-473-6666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC52202
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: