Provider Demographics
NPI:1023221157
Name:SHIVAKUMAR, DEEPTI (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPTI
Middle Name:
Last Name:SHIVAKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 W NORTH AVE
Mailing Address - Street 2:SUITE 416
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1634
Mailing Address - Country:US
Mailing Address - Phone:708-681-7818
Mailing Address - Fax:708-681-7903
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE 416
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-681-7818
Practice Address - Fax:708-681-7903
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036128856207Q00000X
OH35.089615207Q00000X
SC30747207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000269233OtherHMSA BILLING NUMBER
HI59958-01Medicaid
HI59958-01Medicaid