Provider Demographics
NPI:1184609240
Name:SHRIVASTAVA, RAJ K (MD)
Entity type:Individual
Prefix:
First Name:RAJ
Middle Name:K
Last Name:SHRIVASTAVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 E 98TH ST
Mailing Address - Street 2:BOX 1136
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6501
Mailing Address - Country:US
Mailing Address - Phone:212-241-6147
Mailing Address - Fax:212-241-3252
Practice Address - Street 1:5 E 98TH ST
Practice Address - Street 2:BOX 1136
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:212-241-6147
Practice Address - Fax:212-241-3252
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2242811207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02664762Medicaid
I22017Medicare UPIN
NY6014N1Medicare ID - Type Unspecified