Provider Demographics
NPI:1710947502
Name:SRIVASTAVA, ANIL K (MD)
Entity Type:Individual
Prefix:MR
First Name:ANIL
Middle Name:K
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 1:6060 N FOUNTAIN PLAZA DR STE 270
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7873
Mailing Address - Country:US
Mailing Address - Phone:520-229-2578
Mailing Address - Fax:520-229-2561
Practice Address - Street 1:6060 N FOUNTAIN PLAZA DR STE 270
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7873
Practice Address - Country:US
Practice Address - Phone:520-229-2578
Practice Address - Fax:520-229-2561
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27855207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ499138Medicaid
AZ78233Medicare ID - Type Unspecified
AZ499138Medicaid
AZZ109545Medicare PIN