Provider Demographics
NPI:1396021770
Name:SHRIVASTAVA, KAUSTUBH KAILASH (MD)
Entity Type:Individual
Prefix:
First Name:KAUSTUBH
Middle Name:KAILASH
Last Name:SHRIVASTAVA
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 1:61 LEDGELAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BAR HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04609-1303
Mailing Address - Country:US
Mailing Address - Phone:567-210-0190
Mailing Address - Fax:
Practice Address - Street 1:30 E APPLE ST STE NW3300
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-8394
Practice Address - Fax:937-208-8388
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD19979207R00000X
OH35.130715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine