Provider Demographics
NPI:1588603369
Name:SRIVATSA, SANJAY S (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:S
Last Name:SRIVATSA
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 1:7206 N MILBURN AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-8450
Mailing Address - Country:US
Mailing Address - Phone:559-224-5003
Mailing Address - Fax:559-271-8040
Practice Address - Street 1:7206 N MILBURN AVE STE 105
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-8450
Practice Address - Country:US
Practice Address - Phone:559-224-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51208207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF36488Medicare UPIN