Provider Demographics
NPI:1194739425
Name:SRINIVAS, SHYAM
Entity type:Individual
Prefix:
First Name:SHYAM
Middle Name:
Last Name:SRINIVAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PASTEUR DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:SUITE 200
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-723-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1399172085N0904X, 2085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2672666Medicaid
OHI57061Medicare UPIN
OH2672666Medicaid