Provider Demographics
NPI:1760482129
Name:JAWALEKAR, SHREENIWAS R (MD)
Entity Type:Individual
Prefix:
First Name:SHREENIWAS
Middle Name:R
Last Name:JAWALEKAR
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:PO BOX 3444
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25334-3444
Mailing Address - Country:US
Mailing Address - Phone:304-925-5486
Mailing Address - Fax:304-925-8075
Practice Address - Street 1:3508 STAUNTON AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1477
Practice Address - Country:US
Practice Address - Phone:304-925-4086
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV120607207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0063869000Medicaid
WV0063869000Medicaid
WVJA0649404Medicare ID - Type Unspecified