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General NPI Number Information
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NPI Number | 1902455504
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Entity Type | Individual
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Provider Name | SREEDHAR REDDY MITTA
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Gender | Male
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Dates
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Enumeration Date | 09/05/2019
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Last Update Date | 08/16/2022
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Provider Practice Location Address
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Address Line | 2425 FAIRLAWN DR
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City | CARTHAGE
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State | MO
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Zip | 64836-3517
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Country | US
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Telephone | 417-237-0983
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Fax |
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Provider Business Mailing Address
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Address Line | 2425 FAIRLAWN DR
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City | CARTHAGE
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State | MO
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Zip | 64836-3517
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Country | US
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Telephone | 417-237-0983
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Fax |
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 4351045516
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 2022030304
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License Number State | MO
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