Healthcare Provider Details

I. General information

NPI: 1487821898
Provider Name (Legal Business Name): SREEKANTH R DEPA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-4541
  • Fax: 318-966-4543
Mailing address:
  • Phone: 225-526-0002
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number204806
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: