Provider Demographics
NPI:1053617290
Name:DARISETTY, SRIRAM (MD)
Entity type:Individual
Prefix:DR
First Name:SRIRAM
Middle Name:
Last Name:DARISETTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 W CHAMBERS ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1650
Mailing Address - Country:US
Mailing Address - Phone:414-874-4316
Mailing Address - Fax:
Practice Address - Street 1:5000 W CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1650
Practice Address - Country:US
Practice Address - Phone:414-874-4316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-06
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine