Healthcare Provider Details

I. General information

NPI: 1053706952
Provider Name (Legal Business Name): ANSHUL KUMAR SRIVASTAVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 HARRISON AVE FL PRESTON3
BOSTON MA
02118-2309
US

IV. Provider business mailing address

801 ALBANY ST FL G
BOSTON MA
02119-3791
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-7490
  • Fax: 617-414-8742
Mailing address:
  • Phone: 617-414-5405
  • Fax: 617-414-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number286509
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number286509
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: