Provider Demographics
NPI:1083899132
Name:SRIVASTAVA, PIYUSH (MD)
Entity Type:Individual
Prefix:DR
First Name:PIYUSH
Middle Name:
Last Name:SRIVASTAVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 PACIFIC AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5749
Mailing Address - Country:US
Mailing Address - Phone:310-463-8773
Mailing Address - Fax:
Practice Address - Street 1:3715 PACIFIC AVE APT 3
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5749
Practice Address - Country:US
Practice Address - Phone:310-463-8773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82591207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA82591OtherCALIFORNIA LICENSE