Provider Demographics
NPI:1558393322
Name:SRIVASTAVA, SHANTA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANTA
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 1:811 E ELEVENTH ST
Mailing Address - Street 2:SUITE #104
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:909-985-0793
Mailing Address - Fax:909-985-8326
Practice Address - Street 1:811 E ELEVENTH ST
Practice Address - Street 2:SUITE #104
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-985-0793
Practice Address - Fax:909-985-8326
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34126207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA27382Medicare UPIN
CA00A341260Medicare ID - Type Unspecified