Healthcare Provider Details

I. General information

NPI: 1194734087
Provider Name (Legal Business Name): AJAY VENKATESH SRIVASTAVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 12/14/2024
Certification Date: 12/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 KETTNER BLVD STE 100
SAN DIEGO CA
92101-5373
US

IV. Provider business mailing address

1440 COLUMBIA ST APT 1812
SAN DIEGO CA
92101-3481
US

V. Phone/Fax

Practice location:
  • Phone: 844-989-4744
  • Fax:
Mailing address:
  • Phone: 203-415-7473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberA121488
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA121488
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License NumberA121488
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: