Healthcare Provider Details

I. General information

NPI: 1740411925
Provider Name (Legal Business Name): SRIKANTH MAHAVADI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9050 POCAHONTAS TRAIL SUITE F
PROVIDENCE FORGE VA
23140
US

IV. Provider business mailing address

PO BOX 357
PROVIDENCE FORGE VA
23140-0357
US

V. Phone/Fax

Practice location:
  • Phone: 804-966-8350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: SRIKANTH MAHAVADI
Title or Position: OWNER
Credential:
Phone: 804-829-8999