Provider Demographics
NPI:1013404938
Name:KEDIA, SHIVAM RAM (DO)
Entity Type:Individual
Prefix:DR
First Name:SHIVAM
Middle Name:RAM
Last Name:KEDIA
Suffix:
Gender:M
Credentials:DO
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-371-1153
Mailing Address - Fax:859-647-5113
Practice Address - Street 1:7766 EWING BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-7537
Practice Address - Country:US
Practice Address - Phone:859-371-1153
Practice Address - Fax:859-647-5113
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP272207Q00000X
390200000X
KY05102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program