Healthcare Provider Details

I. General information

NPI: 1275819526
Provider Name (Legal Business Name): SIREESHA DATLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SIREESHA DATLA MD

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 09/05/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 5TH AVE N STE 505
ST PETERSBURG FL
33705-1455
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 727-821-0017
  • Fax: 727-822-7473
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number263027
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberME161713
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number57785
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number263027
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberME161713
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: