Provider Demographics
NPI:1679956973
Name:SRIVASTAV, PRIYANKA
Entity type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:SRIVASTAV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:3635 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5711
Practice Address - Country:US
Practice Address - Phone:228-872-2403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-04
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26045207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04008751Medicaid