Healthcare Provider Details

I. General information

NPI: 1073660080
Provider Name (Legal Business Name): MADHANIKA LAASYA SRIRAMA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 POTRERO AVE L UNIT
SAN FRANCISCO CA
94110-2869
US

IV. Provider business mailing address

1380 HOWARD ST 5TH FLOOR
SAN FRANCISCO CA
94103-2638
US

V. Phone/Fax

Practice location:
  • Phone: 510-317-1437
  • Fax: 510-276-6828
Mailing address:
  • Phone: 415-255-3919
  • Fax: 415-255-3567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA83510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: