Provider Demographics
NPI:1184731440
Name:SRIVASTAVA, SHACHI (MD)
Entity type:Individual
Prefix:
First Name:SHACHI
Middle Name:
Last Name:SRIVASTAVA
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:PO BOX 6518
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93386-6518
Mailing Address - Country:US
Mailing Address - Phone:661-664-0212
Mailing Address - Fax:661-664-0270
Practice Address - Street 1:9610 STOCKDALE HWY
Practice Address - Street 2:SUITE C
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311
Practice Address - Country:US
Practice Address - Phone:661-664-0212
Practice Address - Fax:661-664-0270
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH36291Medicare UPIN
CAA00710870Medicare ID - Type Unspecified