Provider Demographics
NPI:1366408221
Name:SRIVASTAVA, SHASHANK CHANDRA (DPM)
Entity type:Individual
Prefix:
First Name:SHASHANK
Middle Name:CHANDRA
Last Name:SRIVASTAVA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 RESEARCH BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3215
Mailing Address - Country:US
Mailing Address - Phone:301-330-0468
Mailing Address - Fax:301-330-3489
Practice Address - Street 1:2401 RESEARCH BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3215
Practice Address - Country:US
Practice Address - Phone:301-330-0468
Practice Address - Fax:301-330-3489
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2010-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01392213E00000X
DCPO1000041213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1811181928OtherGROUP NPI
MD406228100Medicaid
MD406228100Medicaid
MD5329910001Medicare NSC