Provider Demographics
NPI:1306192604
Name:SHIVARAM, PUSHPA (MD)
Entity Type:Individual
Prefix:
First Name:PUSHPA
Middle Name:
Last Name:SHIVARAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PUSHPALATHA
Other - Middle Name:
Other - Last Name:KRISHNAPPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 15TH STREET
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-8623
Mailing Address - Fax:706-721-1459
Practice Address - Street 1:1000 N OAK AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-5703
Practice Address - Country:US
Practice Address - Phone:715-387-5267
Practice Address - Fax:715-389-3142
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0802402080P0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program