Healthcare Provider Details

I. General information

NPI: 1568569002
Provider Name (Legal Business Name): RAJENDU SRIVASTAVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTH MEDICAL DRIVE
SALT LAKE CITY UT
84113
US

IV. Provider business mailing address

100 NORTH MEDICAL DRIVE
SALT LAKE CITY UT
84113
US

V. Phone/Fax

Practice location:
  • Phone: 801-588-3813
  • Fax:
Mailing address:
  • Phone: 801-588-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number49058681205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number49058681205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: