Provider Demographics
NPI:1417231267
Name:SRIVASTAVA, PRIYASHA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRIYASHA
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 1:1505 N PEORIA AVE
Mailing Address - Street 2:#407
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3140
Mailing Address - Country:US
Mailing Address - Phone:309-210-7875
Mailing Address - Fax:
Practice Address - Street 1:1505 N PEORIA AVE
Practice Address - Street 2:#407
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3140
Practice Address - Country:US
Practice Address - Phone:309-210-7875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10749000207RC0200X, 207RP1001X, 207R00000X
IL125059257207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease