Provider Demographics
NPI:1043250863
Name:SHRIVASTAVA, RAKESH (MD)
Entity type:Individual
Prefix:
First Name:RAKESH
Middle Name:
Last Name:SHRIVASTAVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8350
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-8350
Mailing Address - Country:US
Mailing Address - Phone:405-861-0004
Mailing Address - Fax:855-680-8890
Practice Address - Street 1:105 S BRYANT AVE STE 101
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6330
Practice Address - Country:US
Practice Address - Phone:405-861-0004
Practice Address - Fax:855-680-8890
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27981207RI0011X, 207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
000924679001OtherHEALTHNOW
MDG288OtherPREFERRED CARE MCO
P010001487OtherBLUE CHOICE MCO
P010001487OtherMONROE PLAN
107177BJOtherPREFERRED CARE MCO
9704619OtherGHI
000924679001OtherHEALTHNOW