Provider Demographics
NPI:1275767030
Name:SRIVASTAVA, PUJA KESARI (MD)
Entity Type:Individual
Prefix:DR
First Name:PUJA KESARI
Middle Name:
Last Name:SRIVASTAVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIMPLE
Other - Middle Name:
Other - Last Name:SRIVASTAVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4685 FOREST AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3359
Mailing Address - Country:US
Mailing Address - Phone:513-853-4721
Mailing Address - Fax:513-852-8525
Practice Address - Street 1:375 DIXMYTH AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2475
Practice Address - Country:US
Practice Address - Phone:513-862-2864
Practice Address - Fax:513-862-2573
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35120267207QH0002X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program