Healthcare Provider Details

I. General information

NPI: 1962887778
Provider Name (Legal Business Name): SRIKANTH NITHYANANDAM M.B.B.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2285 EXECUTIVE DR STE 110
LEXINGTON KY
40505-4810
US

IV. Provider business mailing address

2285 EXECUTIVE DR STE 110
LEXINGTON KY
40505-4810
US

V. Phone/Fax

Practice location:
  • Phone: 859-374-3529
  • Fax: 859-994-5736
Mailing address:
  • Phone: 859-550-3796
  • Fax: 859-994-5736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51672
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number51672
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: