Basic Information
| Provider Information | |||||||||
| NPI: | 1891946646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADDIPATLA | ||||||||
| FirstName: | SREERAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9430 TURKEY LAKE RD STE 218 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328198015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076483800 | ||||||||
| FaxNumber: | 4074255203 | ||||||||
| Practice Location | |||||||||
| Address1: | 9430 TURKEY LAKE RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328198015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076483800 | ||||||||
| FaxNumber: | 4074255203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2008 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RH0003X | ME102364 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 001904900 | 05 | FL | MEDICAID | ME102364 | 01 | FL | MEDICAL LICENSE | OTHER |