Provider Demographics
NPI:1699000158
Name:SHRIVATSA, SHWETHA SUDHEENDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHWETHA
Middle Name:SUDHEENDRA
Last Name:SHRIVATSA
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 1:740 ROUTE 1 N
Mailing Address - Street 2:
Mailing Address - City:ISELIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08830-2652
Mailing Address - Country:US
Mailing Address - Phone:732-362-3840
Mailing Address - Fax:732-362-3850
Practice Address - Street 1:4510 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3602
Practice Address - Country:US
Practice Address - Phone:215-744-1302
Practice Address - Fax:215-744-2544
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10108100207VG0400X
PAMD447014207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology