Healthcare Provider Details

I. General information

NPI: 1891432910
Provider Name (Legal Business Name): SREENIVASA RAO TADIKONDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2022
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 EZELLE ST
RUSTON LA
71270-7218
US

IV. Provider business mailing address

120 PALEO DR
MONROE LA
71203-8844
US

V. Phone/Fax

Practice location:
  • Phone: 318-251-3126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: SREENIVASA TADIKONDA
Title or Position: OWNER/PROVIDER
Credential: MD
Phone: 318-547-0466