Healthcare Provider Details

I. General information

NPI: 1558616300
Provider Name (Legal Business Name): ANOOP KUMAR HOLALAKERE SREENIVASA RAO M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 ELM STREET
CLAREMONT NH
03743-2099
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 603-542-7771
  • Fax: 603-543-6950
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2018-0201
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number17060
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: