Basic Information
| Provider Information | |||||||||
| NPI: | 1508038787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BHANDARAM | ||||||||
| FirstName: | SRIVIDYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VOOTUKURU | ||||||||
| OtherFirstName: | SRIVIDYA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 130 RAMPART WAY | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802306440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033274700 | ||||||||
| FaxNumber: | 3033274711 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 E 9TH AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039910993 | ||||||||
| FaxNumber: | 3035316583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2008 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 104410 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 52400 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 57-012997 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 49537 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.