Healthcare Provider Details

I. General information

NPI: 1629548672
Provider Name (Legal Business Name): LAKSHMI DURGA SRIRAMULU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CONGER ST APT 611A
BLOOMFIELD NJ
07003-3321
US

IV. Provider business mailing address

40 CONGER ST APT 611A
BLOOMFIELD NJ
07003-3321
US

V. Phone/Fax

Practice location:
  • Phone: 972-207-1828
  • Fax:
Mailing address:
  • Phone: 972-207-1828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2019-01863
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: