Provider Demographics
NPI:1639187479
Name:SHRIVASTAVA, SANJAY (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:SHRIVASTAVA
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 1:133 BROOKLINE AVE FL 9
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3904
Mailing Address - Country:US
Mailing Address - Phone:617-421-6050
Mailing Address - Fax:617-421-6083
Practice Address - Street 1:133 BROOKLINE AVE FL 9
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-6050
Practice Address - Fax:617-421-6083
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222038207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ29717OtherBLUE CROSS
MA2112051Medicaid
MA0037106OtherNEIGHBORHOOD HEALTH PLAN
MA453478OtherTUFTS HEALTH PLAN
MA6529879OtherCIGNA
MAAA49898OtherHARVARD PILGRIM
MAG97018Medicare UPIN
MA0037106OtherNEIGHBORHOOD HEALTH PLAN