Basic Information
| Provider Information | |||||||||
| NPI: | 1063899656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SREENIVASARAO | ||||||||
| FirstName: | KANDIPATI | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549354560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268340 | ||||||||
| FaxNumber: | 9209268370 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 S MOUNTIN DR | ||||||||
| Address2: | |||||||||
| City: | MAYVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530501498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203877500 | ||||||||
| FaxNumber: | 9203877596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2015 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 68639 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.