Provider Demographics
NPI:1336330570
Name:SIVADASAN, MINI I (MD)
Entity Type:Individual
Prefix:DR
First Name:MINI
Middle Name:
Last Name:SIVADASAN
Suffix:I
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 WHEATLAND RD PAV I STE 202
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-5031
Mailing Address - Country:US
Mailing Address - Phone:972-780-5888
Mailing Address - Fax:972-780-5886
Practice Address - Street 1:3430 WHEATLAND RD BUILDING 1 SUITE 202
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-7523
Practice Address - Country:US
Practice Address - Phone:972-780-5888
Practice Address - Fax:972-780-5886
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068886A208G00000X
WI55502-20208G00000X
IL036126598208G00000X
390200000X
TXS1921208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1336330570Medicaid
IN201014710DMedicaid
IN201014710BMedicaid
IL036126598Medicaid
IL01618941OtherBLUECROSS/BLUESHIELD IL
IN201014710CMedicaid
WI1336330570Medicaid
IN201014710AMedicaid
IN201014710EMedicaid
WIWI2609006Medicare PIN
IN201014710DMedicaid
IN201014710AMedicaid
IN201014710EMedicaid
ILP00946162Medicare PIN
IL036126598Medicaid
WIWI2355010Medicare PIN