Basic Information
| Provider Information | |||||||||
| NPI: | 1891704565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JATLA | ||||||||
| FirstName: | SRIDHAR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6983 HILLSDALE CT | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178498350 | ||||||||
| FaxNumber: | 3175766311 | ||||||||
| Practice Location | |||||||||
| Address1: | 2330 S DIXON RD | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469026411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654558822 | ||||||||
| FaxNumber: | 7658653935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 01063214A | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084S0012X | 01063214A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200903530 | 05 | IN | MEDICAID |