1043250863 NPI number — RAKESH SHRIVASTAVA MD

Table of content: RAKESH SHRIVASTAVA MD (NPI 1043250863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043250863 NPI number — RAKESH SHRIVASTAVA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHRIVASTAVA
Provider First Name:
RAKESH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043250863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73083-8350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-861-0004
Provider Business Mailing Address Fax Number:
855-680-8890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 S BRYANT AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73034-6330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-861-0004
Provider Business Practice Location Address Fax Number:
855-680-8890
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0011X , with the licence number:  27981 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 27981 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000924679001 . This is a "HEALTHNOW" identifier . This identifiers is of the category "OTHER".
  • Identifier: MDG288 . This is a "PREFERRED CARE MCO" identifier . This identifiers is of the category "OTHER".
  • Identifier: P010001487 . This is a "BLUE CHOICE MCO" identifier . This identifiers is of the category "OTHER".
  • Identifier: P010001487 . This is a "MONROE PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 107177BJ . This is a "PREFERRED CARE MCO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9704619 . This is a "GHI" identifier . This identifiers is of the category "OTHER".




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