Provider Demographics
NPI:1770565905
Name:SRIVASTAVA, MADHAV K (MD)
Entity type:Individual
Prefix:
First Name:MADHAV
Middle Name:K
Last Name:SRIVASTAVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MADHAV
Other - Middle Name:KUMAR
Other - Last Name:SRIVASTAVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4920 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2272
Mailing Address - Country:US
Mailing Address - Phone:815-226-1906
Mailing Address - Fax:815-226-8474
Practice Address - Street 1:4920 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2272
Practice Address - Country:US
Practice Address - Phone:815-226-1906
Practice Address - Fax:815-226-8474
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360611062084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL791133506OtherRETIRED RAILROAD
IL036061106Medicaid
IL008839OtherHEALTH ALLIANCE
IL0010100569OtherBCBS
IL008839OtherHEALTH ALLIANCE
C45565Medicare UPIN