Provider Demographics
NPI:1528000973
Name:SRIVASTAVA, MANJUL (MD)
Entity Type:Individual
Prefix:
First Name:MANJUL
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 1:6060 N FOUNTAIN PLAZA DR
Mailing Address - Street 2:SUITE 270
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7870
Mailing Address - Country:US
Mailing Address - Phone:520-229-2578
Mailing Address - Fax:
Practice Address - Street 1:6060 N FOUNTAIN PLAZA DR
Practice Address - Street 2:SUITE 270
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7870
Practice Address - Country:US
Practice Address - Phone:520-229-2578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35504207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ111163Medicaid
AZ35504OtherMD LIC
AZ111163Medicaid