Healthcare Provider Details

I. General information

NPI: 1154313476
Provider Name (Legal Business Name): SRINATH REDDY KOSANAM M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 POLO PARK EAST BLVD
DAVENPORT FL
33897-9407
US

IV. Provider business mailing address

10603 EMERALD CHASE DR
ORLANDO FL
32836-5855
US

V. Phone/Fax

Practice location:
  • Phone: 863-424-8900
  • Fax: 863-424-8823
Mailing address:
  • Phone: 863-424-8900
  • Fax: 863-424-8823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME78339
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: