Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 2005025981 | MO |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 2005025981 | MO |
NPI | 1184691305 |
---|---|
Provider Name | Dr. Srinath Tadakamalla |
First Address | Overland Park, KS 66283-3085 |
Second Address | Harrisonville, MO 64701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/03/2006 |
Last Update Date | 23/08/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
207472903 | (05) | MO |
BT7401728 | DEA (01) | MO |
I02298 | (02) |