Provider Demographics
NPI:1750630125
Name:JAVVAJI, SRIMANASI (MD)
Entity Type:Individual
Prefix:
First Name:SRIMANASI
Middle Name:
Last Name:JAVVAJI
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 1:2604B EL CAMINO REAL STE 364
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 S 8TH AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7118
Practice Address - Country:US
Practice Address - Phone:928-788-0785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR3351207N00000X, 207ND0101X
WI3116-320207N00000X
CAA141780207ND0101X
AZ68538207ND0101X
IL125.061605207R00000X
MN74511207ND0101X
MO2023009444207ND0101X
GA94587207ND0101X
OH35.147986207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1750630125Medicaid