Provider Demographics
NPI:1952378309
Name:SHRIVASTAV, RAJENDRA (MD)
Entity Type:Individual
Prefix:
First Name:RAJENDRA
Middle Name:
Last Name:SHRIVASTAV
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 1:1512 W REYNOLDS ST
Mailing Address - Street 2:STE. B
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9781
Mailing Address - Country:US
Mailing Address - Phone:815-842-3023
Mailing Address - Fax:815-842-3241
Practice Address - Street 1:1512 W REYNOLDS ST
Practice Address - Street 2:STE. B
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9781
Practice Address - Country:US
Practice Address - Phone:815-842-3023
Practice Address - Fax:815-842-3241
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD09855Medicare UPIN