Provider Demographics
NPI:1760828842
Name:JASTI, SRAVAN KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:SRAVAN
Middle Name:KUMAR
Last Name:JASTI
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 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3605
Practice Address - Fax:217-383-2704
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD449196207RN0300X
IL036138614207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102855372Medicaid
308554Medicare PIN