Provider Demographics
NPI:1487040036
Name:SRIVASTAVA, GAURAV (MD)
Entity Type:Individual
Prefix:DR
First Name:GAURAV
Middle Name:
Last Name:SRIVASTAVA
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 1:2002 MEDICAL PKWY STE 320
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7901
Mailing Address - Country:US
Mailing Address - Phone:410-571-8733
Mailing Address - Fax:
Practice Address - Street 1:2002 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3046
Practice Address - Country:US
Practice Address - Phone:410-571-8733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD87598207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program