Healthcare Provider Details

I. General information

NPI: 1760482129
Provider Name (Legal Business Name): SHREENIWAS R JAWALEKAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3508 STAUNTON AVE SE
CHARLESTON WV
25304-1477
US

IV. Provider business mailing address

PO BOX 3444
CHARLESTON WV
25334-3444
US

V. Phone/Fax

Practice location:
  • Phone: 304-925-4086
  • Fax:
Mailing address:
  • Phone: 304-925-5486
  • Fax: 304-925-8075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number120607
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: