Healthcare Provider Details

I. General information

NPI: 1275767030
Provider Name (Legal Business Name): PUJA KESARI SRIVASTAVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIMPLE SRIVASTAVA MD

II. Dates (important events)

Enumeration Date: 05/08/2009
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 DIXMYTH AVE
CINCINNATI OH
45220-2475
US

IV. Provider business mailing address

4685 FOREST AVE SUITE C
CINCINNATI OH
45212-3359
US

V. Phone/Fax

Practice location:
  • Phone: 513-862-2864
  • Fax: 513-862-2573
Mailing address:
  • Phone: 513-853-4721
  • Fax: 513-852-8525

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 TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number35120267
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: