Basic Information
Provider Information
NPI: 1174805642
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MIDTHANA
FirstName: SRINIVASA
MiddleName: RAO
NamePrefix: DR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 44 JUDSON ST
Address2: APT-4B
City: EDISON
State: NJ
PostalCode: 088372436
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1025 EL PASEO RD
Address2:  
City: LAS CRUCES
State: NM
PostalCode: 88001
CountryCode: US
TelephoneNumber: 8889884066
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/12/2011
LastUpdateDate: 09/12/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001XDD3595NMY Dental ProvidersDentistGeneral Practice

No ID Information.


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