Provider Demographics
NPI:1033193891
Name:VIGNESH, SHIVAKUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIVAKUMAR
Middle Name:
Last Name:VIGNESH
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 1:2946 E BANNER GATEWAY DR., SUITE 400
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234
Mailing Address - Country:US
Mailing Address - Phone:480-256-3332
Mailing Address - Fax:813-449-8028
Practice Address - Street 1:2946 E BANNER GATEWAY DR., SUITE 400
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-256-3332
Practice Address - Fax:813-449-8028
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040551207RG0100X
FLME102765207RG0100X
AZ64480207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001405514Medicaid
CT100000372Medicare ID - Type Unspecified
CT001405514Medicaid