Healthcare Provider Details

I. General information

NPI: 1225590268
Provider Name (Legal Business Name): SIRISHA GUDLAWAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 WATERTOWN PLANK RD
MILWAUKEE WI
53226-3548
US

IV. Provider business mailing address

7877 W OAKWOOD WAY
FRANKLIN WI
53132-3500
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-8296
  • Fax:
Mailing address:
  • Phone: 734-635-9406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number77810-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number77810-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: