=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588979124
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHASHANK C. SRIVASTAVA, DPM, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2010
-----------------------------------------------------
Last Update Date | 01/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1145 19TH STREET, NW SUITE 409
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20036-3716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-237-2106
-----------------------------------------------------
Fax | 301-330-3489
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2401 RESEARCH BLVD SUITE 350
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20850-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-330-0468
-----------------------------------------------------
Fax | 301-330-3489
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHASHANK CHANDRA SRIVASTAVA
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 301-330-0468
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | PO1000041
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------