Provider Demographics
NPI:1548526171
Name:SREENIVASAN, SAMYUKTHA (MD)
Entity type:Individual
Prefix:
First Name:SAMYUKTHA
Middle Name:
Last Name:SREENIVASAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13657 W MCDOWELL RD
Mailing Address - Street 2:SUITE 118
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2601
Mailing Address - Country:US
Mailing Address - Phone:623-935-9494
Mailing Address - Fax:623-935-9292
Practice Address - Street 1:13657 W MCDOWELL RD
Practice Address - Street 2:SUITE 118
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2601
Practice Address - Country:US
Practice Address - Phone:623-935-9494
Practice Address - Fax:623-935-9292
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50094207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine