Healthcare Provider Details

I. General information

NPI: 1598755811
Provider Name (Legal Business Name): SUDHIR PREM SRIVASTAVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 12/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5665 PEACHTREE DUNWOODY RD NE SUITE 200
ATLANTA GA
30342-1764
US

IV. Provider business mailing address

P.O. BOX 70547
MARIETTA GA
30007
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-6104
  • Fax: 404-847-9683
Mailing address:
  • Phone: 770-579-1894
  • Fax: 770-579-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberF3628
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number062083
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: