Provider Demographics
NPI:1073262606
Name:SRIVASTAV, PRAJIN
Entity Type:Individual
Prefix:
First Name:PRAJIN
Middle Name:
Last Name:SRIVASTAV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781008
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1008
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:5230 E STOP 11 RD STE 250
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6399
Practice Address - Country:US
Practice Address - Phone:317-528-8136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000X
IN11022547A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program