Provider Demographics
NPI:1437105921
Name:SRIVASTAVA, VINITA (MD)
Entity Type:Individual
Prefix:MRS
First Name:VINITA
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 1:401 GUESS ST
Mailing Address - Street 2:STE. 100
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4155
Mailing Address - Country:US
Mailing Address - Phone:864-233-2744
Mailing Address - Fax:864-331-2896
Practice Address - Street 1:401 GUESS ST
Practice Address - Street 2:STE. 100
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4155
Practice Address - Country:US
Practice Address - Phone:864-233-2744
Practice Address - Fax:864-331-2896
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18965207R00000X
SC173F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No173F00000XOther Service ProvidersSleep Specialist, PhD
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC189655Medicaid
571107258001OtherBLUE CHOICE SC
G53028Medicare UPIN
571107258001OtherBLUE CHOICE SC