Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | MD475299 | PA |
N | 207Q00000X | Family Doctor | MT215976 | PA |
NPI | 1003308925 |
---|---|
Provider Name | Srikar Vegesna |
First Address | Philadelphia, PA 19129-1302 |
Second Address | Philadelphia, PA 19149-1133 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2018 |
Last Update Date | 02/09/2021 |