Provider Demographics
NPI:1811181928
Name:SHASHANK C. SRIVASTAVA, DPM, LLC
Entity type:Organization
Organization Name:SHASHANK C. SRIVASTAVA, DPM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONWER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHASHANK
Authorized Official - Middle Name:CHANDRA
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-330-0468
Mailing Address - Street 1:2401 RESEARCH BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3215
Mailing Address - Country:US
Mailing Address - Phone:301-330-0468
Mailing Address - Fax:301-330-3489
Practice Address - Street 1:2401 RESEARCH BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3215
Practice Address - Country:US
Practice Address - Phone:301-330-0468
Practice Address - Fax:301-330-3489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01392213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD019525100OtherDME - MEDICAID
MD406228100Medicaid
MD1366408221OtherINDIVIDUAL NPI
MD5329910001Medicare NSC