Provider Demographics
NPI:1336470806
Name:D M SHIVAKUMAR M D P S C
Entity Type:Organization
Organization Name:D M SHIVAKUMAR M D P S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DODDACHALLOR
Authorized Official - Middle Name:MATT
Authorized Official - Last Name:SHIVAKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:270-358-8650
Mailing Address - Street 1:908 S LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:HODGENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42748-1702
Mailing Address - Country:US
Mailing Address - Phone:270-358-8650
Mailing Address - Fax:270-358-0084
Practice Address - Street 1:908 S LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:HODGENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42748-1702
Practice Address - Country:US
Practice Address - Phone:270-358-8650
Practice Address - Fax:270-358-0084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-23
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20452207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64204522Medicaid
KYC75162Medicare UPIN