Basic Information
| Provider Information | |||||||||
| NPI: | 1902084296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SRIVASTAVA | ||||||||
| FirstName: | BHASKAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 LAKE AVE N | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085952655 | ||||||||
| FaxNumber: | 5085952003 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 LAKE AVE N | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085952655 | ||||||||
| FaxNumber: | 5085952003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2008 | ||||||||
| LastUpdateDate: | 06/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 050055 | CT | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 262096 | MA | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.