Provider Demographics
NPI:1790879997
Name:SHREENATH, AJAY IYENGAR (MD)
Entity Type:Individual
Prefix:
First Name:AJAY
Middle Name:IYENGAR
Last Name:SHREENATH
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 1:1704A WAYNE MEMORIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534
Mailing Address - Country:US
Mailing Address - Phone:919-580-1026
Mailing Address - Fax:919-580-1027
Practice Address - Street 1:1704A WAYNE MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534
Practice Address - Country:US
Practice Address - Phone:919-580-1026
Practice Address - Fax:919-580-1027
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200500739207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901460Medicaid
NC5901460Medicaid
2041913Medicare PIN
2344697Medicare PIN