Basic Information
| Provider Information | |||||||||
| NPI: | 1053750489 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRINIVASAN | ||||||||
| FirstName: | VISISH | ||||||||
| MiddleName: | MANI | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 W THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024705560 | ||||||||
| FaxNumber: | 6024705064 | ||||||||
| Practice Location | |||||||||
| Address1: | 1709 DRYDEN RD | ||||||||
| Address2: | STE 750 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137985421 | ||||||||
| FaxNumber: | 7137983739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2013 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 59581 | AZ | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 005314 | 05 | AZ | MEDICAID |