Provider Demographics
NPI:1073514873
Name:SIVAKUMAR, SUBBURAMAN (MD DO)
Entity Type:Individual
Prefix:
First Name:SUBBURAMAN
Middle Name:
Last Name:SIVAKUMAR
Suffix:
Gender:M
Credentials:MD DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33742 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3358
Mailing Address - Country:US
Mailing Address - Phone:248-893-6610
Mailing Address - Fax:248-893-6746
Practice Address - Street 1:33742 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3358
Practice Address - Country:US
Practice Address - Phone:248-893-6610
Practice Address - Fax:248-893-6746
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2021-09-20
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
MISS065284207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2310443OtherCIGNA
MI2604488OtherAETNA
MI1108268931OtherBLUE CROSS BLUE SHIELD
MI4301165Medicaid
MI2310443OtherCIGNA
MI2604488OtherAETNA
MI0N28260Medicare PIN