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General NPI Number Information
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NPI Number | 1508091489
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Entity Type | Individual
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Provider Name | MAMATHA SIRIVOL M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/21/2009
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Last Update Date | 06/04/2024
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Provider Practice Location Address
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Address Line | 350 N COX ST STE 28
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City | ASHEBORO
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State | NC
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Zip | 27203-5514
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Country | US
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Telephone | 336-629-6500
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Fax | 336-629-9500
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Provider Business Mailing Address
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Address Line | 43 WHITING HILL RD STE 300
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City | BREWER
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State | ME
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Zip | 04412-1006
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Country | US
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Telephone | 207-973-5035
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Fax | 207-973-5042
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 57322-20
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD21574
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License Number State | ME
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2024-00275
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License Number State | NC
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