Provider Demographics
NPI:1992755813
Name:SRINIVASAN, SHASHI K (MD)
Entity type:Individual
Prefix:
First Name:SHASHI
Middle Name:K
Last Name:SRINIVASAN
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 1:2441 GREAR ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2749
Mailing Address - Country:US
Mailing Address - Phone:503-588-0469
Mailing Address - Fax:402-559-9840
Practice Address - Street 1:2441 GREAR ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2749
Practice Address - Country:US
Practice Address - Phone:503-588-0469
Practice Address - Fax:402-559-9840
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE21603207R00000X
NEMD26977207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47078557521Medicaid
NEG69260Medicare UPIN
NE47078557521Medicaid