Provider Demographics
NPI:1508031758
Name:SHRESTHA, NIRANJAN (MD, FAAFP)
Entity Type:Individual
Prefix:
First Name:NIRANJAN
Middle Name:
Last Name:SHRESTHA
Suffix:
Gender:M
Credentials:MD, FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 M L KING DR STE 111
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3060
Mailing Address - Country:US
Mailing Address - Phone:618-436-5237
Mailing Address - Fax:618-436-5236
Practice Address - Street 1:1050 M L KING DR STE 111
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3060
Practice Address - Country:US
Practice Address - Phone:618-436-5237
Practice Address - Fax:618-436-5236
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57009736207Q00000X
IL036.122701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine