Provider Demographics
NPI:1477662039
Name:SRIVATSA, ARUN (MD)
Entity Type:Individual
Prefix:
First Name:ARUN
Middle Name:
Last Name:SRIVATSA
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 1:2557 MOWRY AVE
Mailing Address - Street 2:SUITE 12
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1603
Mailing Address - Country:US
Mailing Address - Phone:510-248-1550
Mailing Address - Fax:510-739-5739
Practice Address - Street 1:2557 MOWRY AVE
Practice Address - Street 2:SUITE 12
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1603
Practice Address - Country:US
Practice Address - Phone:510-248-1550
Practice Address - Fax:510-739-5739
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA 106159207RG0100X
NY244991208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYGROUP - 70000AMedicare PIN