Basic Information
Provider Information | |||||||||
NPI: | 1386604049 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SRIVATSAN | ||||||||
FirstName: | JAYARAM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3421 W 9TH ST | ||||||||
Address2: |   | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 507025401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192725000 | ||||||||
FaxNumber: | 3192725264 | ||||||||
Practice Location | |||||||||
Address1: | 3421 W 9TH ST | ||||||||
Address2: |   | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 507025401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192725000 | ||||||||
FaxNumber: | 3192725264 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2006 | ||||||||
LastUpdateDate: | 01/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD-44038 | IA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP3000X | D0076331 | MD | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
ID | Type | State | Issuer | Description | D0076331 | 01 | MD | MARYLAND LICENSE | OTHER | 53601777 | 05 | NY |   | MEDICAID | A400001785 | 01 | NY | EMPIRE MEDICARE | OTHER | 54988250 | 05 | CO |   | MEDICAID |