Provider Demographics
NPI:1356311351
Name:SHIVAKUMAR, DODDACHALLOR MATT (MD,)
Entity Type:Individual
Prefix:DR
First Name:DODDACHALLOR
Middle Name:MATT
Last Name:SHIVAKUMAR
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 1:908 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY20452207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64204522Medicaid
C75162Medicare UPIN
KY64204522Medicaid