Provider Demographics
NPI:1235283292
Name:SURYADEVARA, SIVA (MD)
Entity Type:Individual
Prefix:DR
First Name:SIVA
Middle Name:
Last Name:SURYADEVARA
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:PO BOX 44008
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3065
Mailing Address - Fax:904-244-3102
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:ACC, 5TH FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209
Practice Address - Country:US
Practice Address - Phone:904-244-2655
Practice Address - Fax:904-244-5913
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116319207RC0000X
FLME 116319207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008906600Medicaid
GA003135084AMedicaid
FL14Q8KOtherBCBS
GA003135084AMedicaid