Healthcare Provider Details

I. General information

NPI: 1902455504
Provider Name (Legal Business Name): SREEDHAR REDDY MITTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 FAIRLAWN DR
CARTHAGE MO
64836-3517
US

IV. Provider business mailing address

2425 FAIRLAWN DR
CARTHAGE MO
64836-3517
US

V. Phone/Fax

Practice location:
  • Phone: 417-237-0983
  • Fax:
Mailing address:
  • Phone: 417-237-0983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351045516
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2022030304
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: