Healthcare Provider Details

I. General information

NPI: 1386855484
Provider Name (Legal Business Name): SIREESHA DASARI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 CAMDEN AVE
PARKERSBURG WV
26101-5652
US

IV. Provider business mailing address

PO BOX 609
ELIZABETH WV
26143-0609
US

V. Phone/Fax

Practice location:
  • Phone: 304-917-3733
  • Fax: 304-917-3744
Mailing address:
  • Phone: 304-275-3301
  • Fax: 304-275-4798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23651
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: