Provider Demographics
NPI:1831197656
Name:PANCHAMUKHI, SRIDEVI (MD)
Entity type:Individual
Prefix:
First Name:SRIDEVI
Middle Name:
Last Name:PANCHAMUKHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SRIDEVI
Other - Middle Name:
Other - Last Name:PYDIKONDALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6863 ELDARICA PL
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-8352
Mailing Address - Country:US
Mailing Address - Phone:469-325-1093
Mailing Address - Fax:855-592-0913
Practice Address - Street 1:5140 LEGENDARY DR
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-9042
Practice Address - Country:US
Practice Address - Phone:469-325-1093
Practice Address - Fax:855-592-0913
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2024-05-13
Deactivation Date:2006-03-31
Deactivation Code:
Reactivation Date:2006-05-01
Provider Licenses
StateLicense IDTaxonomies
IL036-101393207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH12137OtherCHAMPVA
ILH12137OtherUNITED HEALTHCARE RR MEDI
ILH12137OtherTRICARE
IL055761OtherHEALTH ALLIANCE
IL422714OtherHEALTHLINK
IL036-101393Medicaid
IL036101393OtherIDPA FEE FOR SERVICE
ILH12137OtherBLUE CROSS BLUE SHIELD
ILH12137OtherCHAMPVA
H12137Medicare UPIN