Provider Demographics
NPI:1043200835
Name:SHIVAKUMAR, BAVIKATTE N (MD)
Entity Type:Individual
Prefix:
First Name:BAVIKATTE
Middle Name:N
Last Name:SHIVAKUMAR
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 1:5041 UTICA RIDGE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3480
Mailing Address - Country:US
Mailing Address - Phone:563-359-9696
Mailing Address - Fax:
Practice Address - Street 1:5041 UTICA RIDGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3480
Practice Address - Country:US
Practice Address - Phone:563-359-9696
Practice Address - Fax:563-359-1730
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22168174400000X
IL036063062174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
B18009Medicare UPIN
ILL55341Medicare ID - Type Unspecified
IA54546Medicare ID - Type Unspecified