Healthcare Provider Details

I. General information

NPI: 1881889970
Provider Name (Legal Business Name): SREENIVASA RAO TADIKONDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TADIKONDA SRINIVASA RAO M.D

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 04/27/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PALEO DR
MONROE LA
71203-8844
US

IV. Provider business mailing address

120 PALEO DR
MONROE LA
71203-8844
US

V. Phone/Fax

Practice location:
  • Phone: 318-651-7410
  • Fax:
Mailing address:
  • Phone: 318-651-7410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD.201751
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD201751
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD.201751
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: