Healthcare Provider Details

I. General information

NPI: 1699000158
Provider Name (Legal Business Name): SHWETHA SUDHEENDRA SHRIVATSA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 FRANKFORD AVE
PHILADELPHIA PA
19124-3602
US

IV. Provider business mailing address

740 ROUTE 1 N
ISELIN NJ
08830-2652
US

V. Phone/Fax

Practice location:
  • Phone: 215-744-1302
  • Fax: 215-744-2544
Mailing address:
  • Phone: 732-362-3840
  • Fax: 732-362-3850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD447014
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number25MA10108100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: