Healthcare Provider Details

I. General information

NPI: 1922110451
Provider Name (Legal Business Name): AJAY SRIVASTAVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN STREET
CINCINNATI OH
45219
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-584-4956
  • Fax: 513-584-5571
Mailing address:
  • Phone: 513-585-5504
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number238576
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberM9674
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number064470
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number35 127306
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: