Provider Demographics
NPI:1841267317
Name:SHRIVASTAVA, DEEPAK K (MD)
Entity type:Individual
Prefix:MR
First Name:DEEPAK
Middle Name:K
Last Name:SHRIVASTAVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:95258-0986
Mailing Address - Country:US
Mailing Address - Phone:209-339-9036
Mailing Address - Fax:209-339-1901
Practice Address - Street 1:500 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9693
Practice Address - Country:US
Practice Address - Phone:209-468-6820
Practice Address - Fax:209-468-6103
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA4577207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A457702Medicaid
CAZZZ20955ZMedicare PIN
CA00A457702Medicaid
E25069Medicare UPIN