Provider Demographics
NPI:1053750489
Name:SRINIVASAN, VISISH MANI (MD)
Entity type:Individual
Prefix:DR
First Name:VISISH
Middle Name:MANI
Last Name:SRINIVASAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:350 W THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4409
Mailing Address - Country:US
Mailing Address - Phone:602-470-5560
Mailing Address - Fax:602-470-5064
Practice Address - Street 1:1709 DRYDEN RD
Practice Address - Street 2:STE 750
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2400
Practice Address - Country:US
Practice Address - Phone:713-798-5421
Practice Address - Fax:713-798-3739
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ59581207T00000X
TXBP10047276390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ005314Medicaid