Provider Demographics
NPI:1598755811
Name:SRIVASTAVA, SUDHIR PREM (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHIR
Middle Name:PREM
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:P.O. BOX 70547
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30007
Mailing Address - Country:US
Mailing Address - Phone:770-579-1894
Mailing Address - Fax:770-579-1899
Practice Address - Street 1:5665 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1764
Practice Address - Country:US
Practice Address - Phone:404-252-6104
Practice Address - Fax:404-847-9683
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3628174400000X
GA062083208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123718204Medicaid
TX060059517OtherRAILROAD MEDICARE
GA511I780011Medicare PIN
TX123718204Medicaid
TXE07989Medicare UPIN