Healthcare Provider Details

I. General information

NPI: 1952378309
Provider Name (Legal Business Name): RAJENDRA SHRIVASTAV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 W REYNOLDS ST STE. B
PONTIAC IL
61764-9781
US

IV. Provider business mailing address

1512 W REYNOLDS ST STE. B
PONTIAC IL
61764-9781
US

V. Phone/Fax

Practice location:
  • Phone: 815-842-3023
  • Fax: 815-842-3241
Mailing address:
  • Phone: 815-842-3023
  • Fax: 815-842-3241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: