Provider Demographics
NPI:1487655957
Name:SRIVASTAVA, PANKAJ (MD)
Entity Type:Individual
Prefix:DR
First Name:PANKAJ
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 1:1445 US HIGHWAY 51 BYP E
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2127
Mailing Address - Country:US
Mailing Address - Phone:731-286-1900
Mailing Address - Fax:731-286-1939
Practice Address - Street 1:1445 US HIGHWAY 51 BYP E
Practice Address - Street 2:SUITE C
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2127
Practice Address - Country:US
Practice Address - Phone:731-286-1900
Practice Address - Fax:731-286-1939
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD34709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000118807OtherBETTER HEALTH
TN3862247Medicaid
4012046OtherBC
62-1815075OtherOMNI
62-1815075OtherOMNI
TN3862247Medicaid