Basic Information
| Provider Information | |||||||||
| NPI: | 1760549240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHREEVATSA | ||||||||
| FirstName: | AJAI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 CHARLESTOWNE CIR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271035716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404658290 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2700 WAYNE MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275349494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197361110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2014-01417 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 89029 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000506289 | 01 | OH | ANTHEM | OTHER | 745494 | 01 | OH | BUCKEYE | OTHER | 415034 | 01 | OH | WELLCARE | OTHER | 1760549240 | 05 | MI | MEDICAID | P00385142 | 01 | OH | RAILROAD MEDICARE | OTHER | 7937887 | 01 | AETNA | OTHER | 000000218191 | 01 | OH | UNISON | OTHER | 2720621 | 05 | OH | MEDICAID |