Healthcare Provider Details

I. General information

NPI: 1699062257
Provider Name (Legal Business Name): PUJA SRIVASTAVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 W MAIN ST
WILMINGTON OH
45177-2174
US

IV. Provider business mailing address

615 ELSINORE PL STE 200
CINCINNATI OH
45202-1457
US

V. Phone/Fax

Practice location:
  • Phone: 513-834-7063
  • Fax:
Mailing address:
  • Phone: 513-834-7063
  • Fax:

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 StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.128078
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number35.128078
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: