Provider Demographics
NPI:1871592345
Name:SRIVASTAVA, BAL KRISHNA (MD)
Entity type:Individual
Prefix:DR
First Name:BAL
Middle Name:KRISHNA
Last Name:SRIVASTAVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5538 PHILADELPHIA DR STE B
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-3061
Mailing Address - Country:US
Mailing Address - Phone:937-424-3589
Mailing Address - Fax:937-424-0093
Practice Address - Street 1:5538 PHILADELPHIA DR STE B
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3061
Practice Address - Country:US
Practice Address - Phone:937-424-3589
Practice Address - Fax:937-424-0093
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072432207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000202320OtherANTHEM
OH2226157Medicaid
OH4274421Medicare PIN
OH000000202320OtherANTHEM