Healthcare Provider Details

I. General information

NPI: 1700292430
Provider Name (Legal Business Name): A BENJAMIN SRIVASTAVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: A BENJAMIN SRIVASTAVA M.D.

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 RIVERSIDE DR UNIT 66
NEW YORK NY
10032-1007
US

IV. Provider business mailing address

1051 RIVERSIDE DR UNIT 66
NEW YORK NY
10032-1007
US

V. Phone/Fax

Practice location:
  • Phone: 646-774-5000
  • Fax:
Mailing address:
  • Phone: 646-774-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number292602
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2016013823
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: