=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003308925
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. SRIKAR VEGESNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2018
-----------------------------------------------------
Last Update Date | 06/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 755 ANNEX, E MCDOWELL RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85006-2506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-412-3684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 755 ANNEX, E MCDOWELL RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85006-2506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-412-3684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD475299
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QS1201X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 76780
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------