Provider Demographics
NPI:1699045740
Name:DR SHRESTHA MD SC
Entity Type:Organization
Organization Name:DR SHRESTHA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIRANJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRESTHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FAAFP
Authorized Official - Phone:567-868-4507
Mailing Address - Street 1:605 SABLE DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-4472
Mailing Address - Country:US
Mailing Address - Phone:567-868-4507
Mailing Address - Fax:877-395-7287
Practice Address - Street 1:1050 M L KING DR
Practice Address - Street 2:SUITE 111
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3060
Practice Address - Country:US
Practice Address - Phone:567-868-4507
Practice Address - Fax:877-397-7287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center