Provider Demographics
NPI:1437117058
Name:SRIVASTAVA, MONIKA (MD)
Entity Type:Individual
Prefix:
First Name:MONIKA
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 1:1600 36TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4875
Mailing Address - Country:US
Mailing Address - Phone:772-567-1164
Mailing Address - Fax:772-567-1501
Practice Address - Street 1:1600 36TH ST STE B
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960
Practice Address - Country:US
Practice Address - Phone:772-567-1164
Practice Address - Fax:772-567-1501
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA227592207N00000X
NY230026207N00000X
NJ25MA083600800207ND0101X
FLME101443207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11571ES531Medicare PIN