Provider Demographics
NPI:1063412757
Name:SRIVASTAVA, POONAM (MD)
Entity type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:SRIVASTAVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 N OLD TRAIL
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-9367
Mailing Address - Country:US
Mailing Address - Phone:570-374-8555
Mailing Address - Fax:570-374-9933
Practice Address - Street 1:1575 N OLD TRAIL
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-9367
Practice Address - Country:US
Practice Address - Phone:570-374-8555
Practice Address - Fax:570-374-9933
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2010-11-12
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
PAMD039325L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007421000009Medicaid
PA1007421000009Medicaid
PAE46220Medicare UPIN