Provider Demographics
NPI:1407102965
Name:SRIVASTAVA, ROMA (MD)
Entity Type:Individual
Prefix:
First Name:ROMA
Middle Name:
Last Name:SRIVASTAVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5053 WOOSTER RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45226-2326
Mailing Address - Country:US
Mailing Address - Phone:513-751-2273
Mailing Address - Fax:513-751-1848
Practice Address - Street 1:4350 MALSBARY RD
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-5665
Practice Address - Country:US
Practice Address - Phone:513-751-2273
Practice Address - Fax:513-751-1848
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100224207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH491500Medicaid