Provider Demographics
NPI:1831622604
Name:DASARI, SUPRIYA REDDY (MD)
Entity type:Individual
Prefix:DR
First Name:SUPRIYA
Middle Name:REDDY
Last Name:DASARI
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 1:710 CORONADO CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4291
Mailing Address - Country:US
Mailing Address - Phone:702-622-0395
Mailing Address - Fax:
Practice Address - Street 1:710 CORONADO CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4291
Practice Address - Country:US
Practice Address - Phone:702-622-0395
Practice Address - Fax:702-602-6800
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA159479207R00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty