Provider Demographics
NPI:1083762884
Name:SIVAKUMAR, KUMARASAMY (MD)
Entity Type:Individual
Prefix:
First Name:KUMARASAMY
Middle Name:
Last Name:SIVAKUMAR
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 1:43723 20TH W ST 203
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-4784
Mailing Address - Country:US
Mailing Address - Phone:661-941-4958
Mailing Address - Fax:661-941-2455
Practice Address - Street 1:44215 15TH ST W
Practice Address - Street 2:SUITE # 307
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4014
Practice Address - Country:US
Practice Address - Phone:661-949-5908
Practice Address - Fax:661-949-5594
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54211207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A542110Medicaid
F98686Medicare UPIN