Healthcare Provider Details

I. General information

NPI: 1760478796
Provider Name (Legal Business Name): VISALAKSHI SRINIVASAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VISA SRINIVASAN

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3661 S BABCOCK ST 2ND FLOOR
MELBOURNE FL
32901-8903
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-7611
  • Fax: 321-727-3738
Mailing address:
  • Phone: 321-434-7611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number35084470
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberME94188
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: